Nursing, Caring, and Complexity Science: For Human ... - Axon
Nursing, Caring, and Complexity Science: For Human ... - Axon Nursing, Caring, and Complexity Science: For Human ... - Axon
Nursing, Caring, and Complexity Science: For Human–Environment Well-Being
- Page 2 and 3: Alice Ware Davidson, RN, PhD, was o
- Page 5 and 6: Nursing, Caring, and Complexity Sci
- Page 7 and 8: Dedications The spirit and creativi
- Page 9: DedicationS ix preventive health pu
- Page 12 and 13: xii contents 5. Why Six Sigma Healt
- Page 15 and 16: Contributors Alan Barnard, RN, PhD,
- Page 17 and 18: CONTRIBUTORS xvii Joy Longo, RN, Ph
- Page 19 and 20: Foreword T his book asks: “What c
- Page 21 and 22: Reflection T his is a long overdue
- Page 23 and 24: Prologue N ursing’s disciplinary
- Page 25 and 26: PROLOGUE xxv caring has become the
- Page 27 and 28: PROLOGUE xxvii the emergence of pat
- Page 29 and 30: PROLOGUE xxix Caritas Process 9: Ad
- Page 31 and 32: PROLOGUE xxxi and ethical behavior
- Page 33 and 34: PROLOGUE xxxiii living organization
- Page 35 and 36: PROLOGUE xxxv Boone, L., & Bowen, D
- Page 37: PROLOGUE xxxvii Turkel, M., & Ray,
- Page 40 and 41: xl Acknowledgments n We are gratefu
- Page 42 and 43: 2 NURSING, CARING, AND COMPLEXITY S
- Page 44 and 45: 4 NURSING, CARING, AND COMPLEXITY S
- Page 46 and 47: 6 NURSING, CARING, AND COMPLEXITY S
- Page 48 and 49: 8 NURSING, CARING, AND COMPLEXITY S
- Page 50 and 51: 10 NURSING, CARING, AND COMPLEXITY
<strong>Nursing</strong>, <strong>Caring</strong>,<br />
<strong>and</strong> <strong>Complexity</strong> <strong>Science</strong>:<br />
<strong>For</strong> <strong>Human</strong>–Environment<br />
Well-Being
Alice Ware Davidson, RN, PhD, was one of the first nurses to study <strong>and</strong> research the<br />
relationship between the Rogerian science of unitary human beings <strong>and</strong> complexity<br />
science in a complex technological environment. She devoted her academic life to<br />
researching complexity sciences, complex health care systems, nursing, <strong>and</strong> health care.<br />
Throughout her career, Dr. Davidson advanced complexity sciences in nursing theory,<br />
research, administration, <strong>and</strong> clinical practice. Dr. Davidson received her doctor of<br />
philosophy degree from the University of Colorado College of <strong>Nursing</strong>, Aurora, Colorado.<br />
She completed postdoctoral studies at Harvard University, studied at the Santa Fe<br />
Institute in New Mexico, <strong>and</strong> the New Engl<strong>and</strong> Center for Complex Systems in Boston,<br />
Massachusetts. In 2005, Dr. Davidson studied with the renowned complexity scientist,<br />
Dr. F. David Peat, in Pari, Italy. Dr. Davidson was an assistant clinical professor at the<br />
University of Colorado, College of <strong>Nursing</strong>, where she taught nursing theory, research, <strong>and</strong><br />
supervised students in clinical nursing practice. In December 2009, Dr. Davidson lost her<br />
battle with cancer. This book is dedicated to Dr. Davidson. Her legacy lives on through the<br />
scholarship on complexity sciences, nursing, <strong>and</strong> caring presented in this book.<br />
Marilyn A. Ray, RN, PhD, CTN-A, Professor Emeritus, Florida Atlantic University, is a<br />
renowned nursing educator <strong>and</strong> researcher of caring in complex health care systems <strong>and</strong><br />
transcultural nursing. She was a colleague <strong>and</strong> good friend of Dr. Alice W. Davidson <strong>and</strong> worked<br />
with her on articles related to complexity sciences <strong>and</strong> nursing. Dr. Ray is an advanced<br />
transcultural nurse committed to the development <strong>and</strong> progress of transcultural caring in<br />
nursing worldwide. She is well known for her theory of bureaucratic caring, which integrates<br />
knowledge of human caring within complex technological, economic, legal, <strong>and</strong> political<br />
systems in hospital organizations. Previous awards include the Christine E. Lynn Eminent<br />
Scholar Chair in <strong>Nursing</strong>, Florida Atlantic University; Yingling Visiting Scholar, Virginia<br />
Commonwealth University; Visiting Lecturer, University of Alberta, Canada, Clinical <strong>Science</strong>s<br />
Division. Ray attended seminars at the Kennedy Institute of Ethics, Georgetown University.<br />
She also studied with Dr. F. David Peat in Pari, Italy, the distinguished physicist in the sciences<br />
of complexity. Other fellowships include the Ministry of Health of Ontario <strong>and</strong> visiting<br />
scholar positions in universities in Australia. She has held faculty positions at the University of<br />
Colorado, College of <strong>Nursing</strong>; the Union Institute, Cincinnati; McMaster University, Hamilton,<br />
Canada; the University of California, School of <strong>Nursing</strong>; <strong>and</strong> the University of San Francisco,<br />
School of <strong>Nursing</strong>. From 1967 to 1999, Dr. Ray served as an officer in the United States Air<br />
<strong>For</strong>ce, beginning first with the Wyoming Air National Guard followed by the United States<br />
Air <strong>For</strong>ce Reserve. She held the rank of Colonel from 1984 to her retirement in 1999. During<br />
her military career, Ray held many diverse positions—flight nurse, educator, researcher, <strong>and</strong><br />
administrator in many USAF Comm<strong>and</strong>s across the United States. She attended the Marshall<br />
Space Center to support the potential role of nursing in space. During the last 8 years of<br />
her career she was a researcher at the USAF School of Aerospace Medicine, Brooks Air <strong>For</strong>ce<br />
Base, Texas. Ray recently completed a book titled Transcultural <strong>Caring</strong> Dynamics in <strong>Nursing</strong><br />
<strong>and</strong> Health Care. She edited one book with Dr. Jean Watson <strong>and</strong> has numerous chapters<br />
<strong>and</strong> peer-reviewed articles in many journals. Her work is translated into different languages.<br />
She has over 20 funded research grants totaling almost one million dollars, <strong>and</strong> presents<br />
nationally <strong>and</strong> internationally, the most recent at the World Universities <strong>For</strong>um in Davos, <strong>and</strong><br />
universities in Lausanne, Switzerl<strong>and</strong>. Ray recently visited the WHO, <strong>and</strong> the International<br />
Council of Nurses in Geneva, Switzerl<strong>and</strong>, sharing knowledge <strong>and</strong> her experience of<br />
transcultural nursing, theory <strong>and</strong> research, <strong>and</strong> a vision for the future of nursing within the<br />
complex global environment.
Marian C. Turkel, RN, PhD, NEA-BC, is the Director of Professional <strong>Nursing</strong> Practice at<br />
Albert Einstein Healthcare Network (AEHN) <strong>and</strong> is on the faculty of the Watson <strong>Caring</strong><br />
<strong>Science</strong> Institute (WCSI). In her role at AEHN she is responsible for advancing Watson’s<br />
theory of human caring, integrating research <strong>and</strong> evidence-based practice initiatives,<br />
creating a professional practice environment, <strong>and</strong> focusing on tenets from complexity<br />
science related to innovation <strong>and</strong> organizational transformation. As part of the faculty<br />
of the WCSI, Dr. Turkel works with various hospitals on the practical application of<br />
the theory <strong>and</strong> does presentations on caring science with an emphasis on education,<br />
leadership, practice, <strong>and</strong> research. Her commitment to advancing caring science <strong>and</strong><br />
valuing caring being the essence of nursing practice started in 1989 when she returned<br />
to school for a master’s in nursing administration at Florida Atlantic University (FAU).<br />
After graduation, Dr. Turkel enrolled in the University of Miami’s PhD program <strong>and</strong><br />
in 1997 she returned to FAU as an assistant professor <strong>and</strong> taught undergraduate <strong>and</strong><br />
graduate theory, research, <strong>and</strong> leadership courses. In 2002 she relocated to Chicago <strong>and</strong><br />
began consulting with various hospitals on developing practice innovations related to<br />
Magnet, creating research initiatives, implementing Watson’s theory of human caring into<br />
the practice setting, <strong>and</strong> working with leaders to underst<strong>and</strong> the core value of caring<br />
in nursing practice. Over the course of her career she has worked in collaboration with<br />
Dr. Marilyn Ray <strong>and</strong> was the coprincipal investigator on almost one million dollars<br />
in federal research funding to study the relationship among caring, economics, <strong>and</strong><br />
patient outcomes. Dr. Turkel authored a textbook on strategies for obtaining Magnet<br />
Program Recognition ® , published in peer-reviewed journals, contributed chapters in<br />
nursing textbooks, <strong>and</strong> presented at numerous national <strong>and</strong> international conferences.<br />
She has been actively involved with the International Association for <strong>Human</strong> <strong>Caring</strong> for<br />
approximately 20 years <strong>and</strong> assumed the role of President Elect in June 2010.
<strong>Nursing</strong>, <strong>Caring</strong>,<br />
<strong>and</strong> <strong>Complexity</strong> <strong>Science</strong>:<br />
<strong>For</strong> <strong>Human</strong>–Environment<br />
Well-Being<br />
Alice Ware Davidson, RN, PhD<br />
Marilyn A. Ray, RN, PhD, CTN-A<br />
Marian C. Turkel, RN, PhD, NEA-BC
Copyright © 2011 Springer Publishing Company, LLC<br />
All rights reserved.<br />
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any<br />
means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer<br />
Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance<br />
Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or<br />
on the web at www.copyright.com.<br />
Springer Publishing Company, LLC<br />
11 West 42nd Street<br />
New York, NY 10036<br />
www.springerpub.com<br />
Acquisitions Editor: Allan Graubard<br />
Senior Editor: Rose Mary Piscitelli<br />
Cover design: Joseph DePinho<br />
Project Manager: Vanavan Jayaraman<br />
Composition: S4Carlisle Publishing Services<br />
ISBN: 978-0-8261-2587-3<br />
E-book ISBN: 978-0-8261-2588-0<br />
11 12 13/ 5 4 3 2 1<br />
The author <strong>and</strong> the publisher of this work have made every effort to use sources believed to be reliable to<br />
provide information that is accurate <strong>and</strong> compatible with the st<strong>and</strong>ards generally accepted at the time of publication.<br />
Because medical science is continually advancing, our knowledge base continues to exp<strong>and</strong>. Therefore,<br />
as new information becomes available, changes in procedures become necessary. We recommend that<br />
the reader always consult current research <strong>and</strong> specific institutional policies before performing any clinical<br />
procedure. The author <strong>and</strong> publisher shall not be liable for any special, consequential, or exemplary damages<br />
resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book.<br />
The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet<br />
Web sites referred to in this publication <strong>and</strong> does not guarantee that any content on such Web sites is, or will<br />
remain, accurate or appropriate.<br />
Library of Congress Cataloging-in-Publication Data<br />
<strong>Nursing</strong>, caring, <strong>and</strong> complexity science: <strong>For</strong> human-environment well being /[edited by] Alice Ware Davidson,<br />
Marilyn A. Ray, Marian C. Turkel.<br />
p. ; cm.<br />
Includes bibliographical references.<br />
ISBN 978-0-8261-2587-3<br />
1. <strong>Nursing</strong> models. 2. <strong>Nursing</strong>—Philosophy. 3. System theory. I. Davidson, Alice Ware, 1945–2009. II.<br />
Ray, Marilyn Anne. III. Turkel, Marian C.<br />
[DNLM: 1. <strong>Nursing</strong> Research. 2. Models, <strong>Nursing</strong>. 3. <strong>Nursing</strong> Care—methods. 4. <strong>Nursing</strong> Theory.<br />
5. Systems Theory. WY 20.5]<br />
RT84.5.N853 2010<br />
610.73—dc22<br />
2010037914<br />
Special discounts on bulk quantities of our books are available to corporations, professional associations,<br />
pharmaceutical companies, health care organizations, <strong>and</strong> other qualifying groups. If you are interested in<br />
a custom book, including chapters from more than one of our titles, we can provide that service as well.<br />
<strong>For</strong> details, please contact:<br />
Special Sales Department<br />
Springer Publishing Company, LLC<br />
11 West 42nd Street, 15th Floor<br />
New York, NY 10036-8002<br />
Phone: 877-687-7476 or 212-431-4370<br />
Fax: 212-941-7842<br />
Email: sales@springerpub.com<br />
Printed in the United States of America by Bang Printing
Dedications<br />
The spirit <strong>and</strong> creativity of this book on complexity science <strong>and</strong> nursing<br />
science first began with the dedication to new knowledge by our colleague<br />
<strong>and</strong> friend, the late Dr. Alice W. Davidson. Over the past 25 years, Alice<br />
encouraged me to pursue the new science <strong>and</strong> reflect on <strong>and</strong> study how the<br />
new cosmology could transform nursing. In conjunction with the philosophy<br />
<strong>and</strong> science of caring, the science of unitary human beings, transcultural<br />
nursing, <strong>and</strong> the study of complexity sciences, I have begun my journey to<br />
underst<strong>and</strong> the meaning of how we, as nurses <strong>and</strong> professors, cocreate the<br />
reality we desire from the spiritual–ethical choices we make. This new consciousness<br />
of the integration of mind, spirit, <strong>and</strong> caring energy illuminates<br />
the significance of the mutual human–environment caring relationship, our<br />
unitary interconnectedness. Through this vision, <strong>and</strong> the love <strong>and</strong> support<br />
of my late husb<strong>and</strong>, Jim, <strong>and</strong> friend Alice, my family, my colleagues, <strong>and</strong><br />
friends, especially my friends <strong>and</strong> co-editor, Dr. Marian Turkel <strong>and</strong> husb<strong>and</strong>,<br />
Brooks, I am committed to continue the effort for clarity of underst<strong>and</strong>ing<br />
the dynamic <strong>and</strong> complex caring relationship, <strong>and</strong> how the world can be<br />
transformed by caring intention, will, knowledge, <strong>and</strong> practical wisdom.<br />
Marilyn A. (Dee) Ray<br />
This book is dedicated to my mentors <strong>and</strong> guides on my journey to underst<strong>and</strong>ing<br />
the scholarship of caring science. Dr. Carolyn Brown, Dr. Anne<br />
Boykin, Dr. Marilyn Parker, Dr. Marilyn Ray, Dr. Savina Schoenhofer, <strong>and</strong><br />
Dr. Jean Watson provided ongoing love, nurturance, <strong>and</strong> support, <strong>and</strong> inspired<br />
me to think differently, conduct research, <strong>and</strong> publish. A special thanks to my<br />
co-editor Dr. Marilyn Ray for believing in me so many years ago <strong>and</strong> inviting<br />
me to become a part of her research <strong>and</strong> scholarship. To the faculty <strong>and</strong> Board<br />
of Directors of the Watson <strong>Caring</strong> <strong>Science</strong> Institute, I am honored to be<br />
on the journey with all of you <strong>and</strong> consider each <strong>and</strong> everyone a special<br />
friend <strong>and</strong> caring colleague. A special dedication to my family, friends,<br />
<strong>and</strong> professional colleagues who understood why I have not been sending<br />
cards or e-mails as much as I have wanted to over the past few months.<br />
I would like to dedicate this book to registered nurses in the practice setting<br />
who have made the personal <strong>and</strong> professional commitment to using<br />
tenets of caring science <strong>and</strong> complexity science to inform practice. You are<br />
vii
viii<br />
DedicationS<br />
the change agents. Most important is the special dedication to my husb<strong>and</strong><br />
Brooks Turkel. Brooks is truly my bashert (soul mate in Judaism). His love<br />
<strong>and</strong> caring energy allow my inner creativity to emerge. He honors, respects,<br />
<strong>and</strong> underst<strong>and</strong>s my passion for reading, reflecting, <strong>and</strong> writing. He is always<br />
there for me as I explore the scholarship of caring science <strong>and</strong> make a humble<br />
attempt to advance the discipline of nursing <strong>and</strong> transform practice.<br />
Marian C. Turkel<br />
This book is dedicated to our colleague <strong>and</strong> friend, Dr. Alice Ware<br />
Davidson. Alice died December 2, 2009, after a relatively short battle<br />
with malignant melanoma, actually while she was in the process of editing<br />
this book with me, Marilyn Dee Ray.<br />
Alice was gifted with a different way of thinking; a scientist, an artist,<br />
<strong>and</strong> a technologist. Alice was one of the first nurse scholars to dedicate her<br />
academic life to the study of holistic science <strong>and</strong> the science of change—<br />
complexity sciences. Alice integrated complexity sciences, Rogers’ science of<br />
unitary human beings, technology, <strong>and</strong> their application to nursing, caring,<br />
health care, <strong>and</strong> the deep meaning of healing <strong>and</strong> well-being within the mutual<br />
human– environment process. Not only did Alice achieve a PhD in complexity<br />
science <strong>and</strong> nursing at the University of Colorado College of <strong>Nursing</strong><br />
under the leadership of the former dean, Dr. Jean Watson, <strong>and</strong> professor<br />
Dr. Marilyn Ray, but also, she continued to further her knowledge of complexity<br />
sciences <strong>and</strong> methodology through the following paths: study <strong>and</strong><br />
postdoctoral work at Harvard University <strong>and</strong> the New Engl<strong>and</strong> Center for<br />
Complex Systems with her mentor, Dr. Yaneer Bar-Yam <strong>and</strong> colleagues; the<br />
University of Colorado Complex Systems Department; the Santa Fe Institute;<br />
<strong>and</strong> in Italy with Dr. F. David Peat, a renowned quantum physicist originally<br />
from the United Kingdom, former Director of the National <strong>Science</strong> Foundation<br />
of Canada, a colleague of scientists, Drs. David Bohm, Rupert Sheldrake, <strong>and</strong><br />
John Briggs, <strong>and</strong> a founder <strong>and</strong> educator of Holistic <strong>Science</strong> at the Pari Center<br />
for New Learning in Pari, Italy, to further the study of the science <strong>and</strong> art of<br />
change <strong>and</strong> holism, healing, <strong>and</strong> well-being. During this time of learning <strong>and</strong><br />
“quiet action” to underst<strong>and</strong> our mysterious universe <strong>and</strong> nursing <strong>and</strong> healing,<br />
Alice raised two wonderful children, Anne <strong>and</strong> John. Both children followed in<br />
Alice’s footsteps. Anne works in Idaho as a scientist, caring for the natural environment<br />
<strong>and</strong> the animals of the earth, <strong>and</strong> John is a chef, preparing nutritious<br />
foods in his restaurant for the people of Denver, Colorado. Alice also leaves a<br />
legacy of love <strong>and</strong> caring to her long-time <strong>and</strong> dedicated partner, John Smith,<br />
<strong>and</strong> her three gr<strong>and</strong>children.<br />
When Alice was diagnosed with malignant melanoma, she was conceiving<br />
the ideas for this book <strong>and</strong> seeking out the many scholars to write chapters<br />
of their conceptualizations <strong>and</strong> research of complexity sciences, nursing,<br />
<strong>and</strong> human–environment well-being. Alice would want you to know for
DedicationS ix<br />
preventive health purposes that the melanoma began with a very tiny mole<br />
between her right baby <strong>and</strong> fourth toes <strong>and</strong> spread throughout her body from<br />
there. Although Alice sought treatment at M. D. Anderson Medical Center in<br />
Houston, <strong>and</strong> other treatments, the cancer progressed. However, the cancer<br />
did not stop her marvelous beliefs <strong>and</strong> creative energy to bring to life the<br />
philosophy, scientific theories, <strong>and</strong> applications to practice that you will experience<br />
from reading this book. Alice was a courageous woman, dedicated to<br />
her family <strong>and</strong> her profession. She loved life! She loved to learn about this<br />
universe <strong>and</strong> health <strong>and</strong> healing. She loved her family <strong>and</strong> friends. She reverenced<br />
the environment not only to underst<strong>and</strong> it through science but also<br />
as an appreciator <strong>and</strong> protector of it through her commitment to what ought<br />
to be in the hearts of all of us, ethical agents or, as Socrates challenged us<br />
thous<strong>and</strong>s of years ago, giving thought <strong>and</strong> action to how we ought to live.<br />
Alice’s humility, respect for all people <strong>and</strong> creatures of the earth, <strong>and</strong> her<br />
sense of reverence for the environment was also lived out in nature at the<br />
home she shared on the Pacific Ocean with John. She enjoyed gardening <strong>and</strong><br />
care for the fauna <strong>and</strong> flora. At her home, she was committed to preserving<br />
the environment in every way so that it can always be balanced <strong>and</strong> beautiful.<br />
Alice felt that each one of us must cultivate love for <strong>and</strong> have an ethical obligation<br />
to protect, preserve, <strong>and</strong> safeguard all that we as humans have been<br />
given. We must think with our hearts <strong>and</strong> minds, with feeling <strong>and</strong> reason.<br />
Alice stated that choice was the “conductor of the symphony” in the balance<br />
<strong>and</strong> beauty of the human–environment relationship. Let us follow in her footsteps<br />
to make the right choices <strong>and</strong> find meaning <strong>and</strong> joy in the preservation<br />
of the beauty of the Universe in this dance of life.<br />
With gratitude to a loving friend for her gifts to us,<br />
Marilyn A. (Dee) Ray<br />
Marian C. Turkel
Contents<br />
Contributors xv<br />
<strong>For</strong>eword by Yaneer Bar-Yam xix<br />
Reflection by Jean Watson xxi<br />
Prologue by Alice W. Davidson, Marilyn A. Ray, Marian C. Turkel<br />
Acknowledgments xxxix<br />
xxiii<br />
1. Philosophical <strong>and</strong> Theoretical Perspectives Related to<br />
<strong>Complexity</strong> <strong>Science</strong> in <strong>Nursing</strong> 1<br />
Marlaine Smith<br />
Respondent: Joyce Perkins<br />
Respondent: Francelyn M. Reeder<br />
2. Complex <strong>Caring</strong> Dynamics: A Unifying Model of<br />
<strong>Nursing</strong> Inquiry 31<br />
Marilyn A. Ray<br />
Respondent: Janice M. Morse<br />
Respondent: Pamela Reed<br />
3. Theoretical Issues <strong>and</strong> Methods for Increasing Underst<strong>and</strong>ing<br />
of Complex Health Care Systems 61<br />
Alice W. Davidson <strong>and</strong> Stefan Topolski<br />
Respondent: Bruce J. West<br />
4. Relational <strong>Caring</strong> <strong>Complexity</strong>: The Study of <strong>Caring</strong> <strong>and</strong><br />
<strong>Complexity</strong> in Health Care Hospital Organizations 95<br />
Marilyn A. Ray, Marian C. Turkel, <strong>and</strong> Jeffrey Cohn<br />
Respondent: Terry Eggenberger<br />
xi
xii<br />
contents<br />
5. Why Six Sigma Health Care Is Oxymoronic<br />
in Hospitals 125<br />
Bruce J. West<br />
Respondent: Michael Brooks Turkel<br />
6. Entropy as Information Content in Medical Research 143<br />
Nikhil S. Padhye<br />
Respondent: Mary Pat Rapp<br />
7. <strong>Caring</strong> <strong>Science</strong> <strong>and</strong> <strong>Complexity</strong> <strong>Science</strong> Guiding the Practice<br />
of Hospital <strong>and</strong> <strong>Nursing</strong> Administrative Practice 169<br />
Mary Beth Kingston <strong>and</strong> Michael Brooks Turkel<br />
Respondent: Jim D’Alfonso<br />
8. Leadership in Complex <strong>Nursing</strong> <strong>and</strong><br />
Health Care Systems 199<br />
Diana M. Crowell<br />
Respondent: Nancy Shirley<br />
9. Mathematical Models of the Dynamics<br />
of Social Conflict 215<br />
Larry Liebovitch, Robin Vallacher, Andrzej Nowak, Peter Coleman,<br />
Andrea Bartoli, <strong>and</strong> Lan Bui-Wrzosinska<br />
Respondent: Lisa Conboy<br />
Respondent: Joy Longo<br />
10. Modeling the <strong>Complexity</strong> of Story Theory for<br />
<strong>Nursing</strong> Practice 241<br />
Patricia Liehr <strong>and</strong> Mary Jane Smith<br />
Respondent: Debra Hain<br />
11. Providing <strong>Nursing</strong> Care in a Complex Health Care<br />
Environment 253<br />
Michael Bleich<br />
Respondent: Mary Gambino<br />
12. The <strong>Complexity</strong> of Diabetes <strong>and</strong> the <strong>Caring</strong> Role of the<br />
Nurse Practitioner 267<br />
Jane Faith Kapustin<br />
Respondent: Sherrilyn Coffman
contents xiii<br />
13. Lessons in <strong>Complexity</strong> <strong>Science</strong>: Preparing Student Nurses for<br />
Practice in Complex Health Care Systems 285<br />
Claire E. Lindberg<br />
Respondent: Patricia Welch Dittman<br />
14. Technological Change in Health Care Electronic Documentation<br />
as Facilitated Through the <strong>Science</strong> of <strong>Complexity</strong> 309<br />
Todd Swinderman<br />
Respondent: Barbara Penprase<br />
15. Implementing Change in <strong>Nursing</strong> Informatics Practice 325<br />
Aric S. Campling, Marilyn A. Ray, <strong>and</strong> Jacqueline M. Lopez-Devine<br />
Respondent: Kathleen Valentine<br />
16. <strong>Human</strong> Rights <strong>and</strong> <strong>Human</strong>oid Relationships in <strong>Nursing</strong><br />
<strong>and</strong> <strong>Complexity</strong> <strong>Science</strong> 345<br />
Rozzano Locsin, Marguerite Purnell, Tetsuya Tanioka, <strong>and</strong><br />
Kyoko Osaka<br />
Respondent: Alan Barnard<br />
Epilogue: Emerging Ideas/Questions for the Future of Nurse <strong>Caring</strong><br />
<strong>and</strong> Health Care in a Complex World 365<br />
Marian C. Turkel <strong>and</strong> Marilyn A. Ray<br />
Addendum 371<br />
Competency Literacy Bingo<br />
Sylvia Bushell <strong>and</strong> Jim D’Alfonso<br />
<strong>Caring</strong> <strong>and</strong> <strong>Complexity</strong> <strong>Science</strong>s: Application to <strong>Nursing</strong> Education,<br />
Leadership, Practice, <strong>and</strong> Research<br />
Jeffrey Cohn, Alice W. Davidson, Claire E. Lindberg, Marilyn A. Ray,<br />
<strong>and</strong> Marian C. Turkel<br />
Index 381
Contributors<br />
Alan Barnard, RN, PhD, MRCNA Senior Lecturer, Queensl<strong>and</strong> University<br />
of Technology, Queensl<strong>and</strong>, Australia<br />
Andrea Bartoli, PhD International Center for Cooperation <strong>and</strong> Conflict<br />
Resolution, Columbia University, New York, NY<br />
Yaneer Bar-Yam, PhD Professor <strong>and</strong> President, New Engl<strong>and</strong> Complex<br />
Systems Institute, Cambridge, MA<br />
Michael Bleich, RN, PhD, FAAN Professor <strong>and</strong> Dean, Oregon Health &<br />
<strong>Science</strong> University, School of <strong>Nursing</strong>, Portl<strong>and</strong>, OR<br />
Lan Bui-Wrzosinska, PhD Warsaw School of Social Psychology, Warsaw,<br />
Pol<strong>and</strong><br />
Sylvia Bushell, MA, CPHQ Founder <strong>and</strong> CEO, BodhiCare, Scottsdale, AZ<br />
Aric S. Campling, RN, MSN Adjunct Instructor, The Christine E. Lynn<br />
College of <strong>Nursing</strong>, Florida Atlantic University, Boca Raton, FL, <strong>and</strong><br />
Clinical Informatics Support Center, Children’s National Medical Center,<br />
Washington, DC<br />
Sherrilyn Coffman, RN, PhD, CS Professor <strong>and</strong> Assistant Dean,<br />
Nevada State College School of <strong>Nursing</strong>, Henderson, NV<br />
Jeffrey Cohn, MD, MHCM Chief Quality Officer, Albert Einstein<br />
Healthcare Network, Philadelphia, PA<br />
Peter Coleman, PhD International Center for Cooperation <strong>and</strong> Conflict<br />
Resolution, Columbia University, New York, NY<br />
Lisa Conboy, MA, MS, ScD Clinical Instructor, Osher Research Center,<br />
Division for Research <strong>and</strong> Education in Complementary <strong>and</strong> Integrative<br />
Medical Therapies, Harvard Medical School, Boston, MA<br />
xv
xvi<br />
contributors<br />
Diana M. Crowell, RN, PhD, CNAA Independent <strong>Nursing</strong> Education <strong>and</strong><br />
Leadership Consultant, Kittery, ME<br />
Jim D’Alfonso, RN, MSN, CNOR Chief Operating Officer/Chief Nurse<br />
Executive, Watson <strong>Caring</strong> <strong>Science</strong> Institute, Scottsdale, AZ<br />
Alice W. Davidson, RN, PhD <strong>For</strong>merly Assistant Clinical Professor,<br />
The Anschutz Medical Campus, University of Colorado, College of <strong>Nursing</strong>,<br />
Aurora, CO<br />
Patricia Welch Dittman, RN, PhD, CDE Assistant Professor, Director,<br />
Graduate Programs, <strong>Nursing</strong> Department, Nova Southeastern University,<br />
<strong>For</strong>t Lauderdale, FL<br />
Terry Eggenberger, RN, PhD(c) Assistant Clinical Professor,<br />
The Christine E. Lynn College of <strong>Nursing</strong>, Florida Atlantic University,<br />
Boca Raton, FL<br />
Mary Gambino, RN, PhD Assistant Dean for Community Affairs,<br />
University of Kansas School of <strong>Nursing</strong>, Kansas City, KS<br />
Debra Hain, RN, DNS Assistant Professor, The Christine E. Lynn College<br />
of <strong>Nursing</strong>, Florida Atlantic University, Boca Raton, FL<br />
Jane Faith Kapustin, RN, PhD Associate Professor, Assistant Dean for<br />
Master’s Programs, University of Maryl<strong>and</strong>, School of <strong>Nursing</strong>, Baltimore, MD<br />
Mary Beth Kingston, RN, MSN, NEA-BC RWJ Executive Nurse Fellow,<br />
Vice President/Chief Nurse Executive, Albert Einstein Healthcare Network,<br />
Philadelphia, PA<br />
Larry Liebovitch, PhD Professor & Dean, Division of Mathematics<br />
<strong>and</strong> Natural <strong>Science</strong>s, Queens College, City University of New York,<br />
New York, NY<br />
Patricia Liehr, RN, PhD Professor <strong>and</strong> Associate Dean for Research,<br />
The Christine E. Lynn College of <strong>Nursing</strong>, Florida Atlantic University,<br />
Boca Raton, FL<br />
Claire E. Lindberg, RN, PhD, APRN, BC Professor, The School of<br />
<strong>Nursing</strong>, The College of New Jersey, Ewing, NJ<br />
Rozzano Locsin, RN, PhD, FAAN John F. Wymer Distinguished Professor<br />
of <strong>Nursing</strong>, The Christine E. Lynn College of <strong>Nursing</strong>, Florida Atlantic<br />
University, Boca Raton, FL
CONTRIBUTORS xvii<br />
Joy Longo, RN, PhD Assistant Professor, The Christine E. Lynn College<br />
of <strong>Nursing</strong>, Florida Atlantic University, Boca Raton, FL<br />
Jacqueline M. Lopez-Devine, RN, MSN Hospice of Palm Beach,<br />
West Palm Beach, FL<br />
Janice M. Morse, RN, PhD (<strong>Nursing</strong>), PhD (Anthropology), FAAN<br />
Professor <strong>and</strong> the Ida May “Dotty” Barnes, RN, <strong>and</strong> D. Keith Barnes, MD,<br />
Presidential Endowed Chair, University of Utah, College of <strong>Nursing</strong>,<br />
Salt Lake City, UT<br />
Andrzej Nowak, PhD University of Warsaw Center for Complex Systems<br />
Research, Warsaw, Pol<strong>and</strong><br />
Kyoko Osaka, RN, PhD Assistant Professor, University of Tokushima, Japan<br />
Nikhil S. Padhye, PhD Department of Research, University of Texas<br />
Health <strong>Science</strong> Center at Houston, Houston, TX<br />
Barbara Penprase, RN, PhD, CNOR Associate Professor, School of<br />
<strong>Nursing</strong>, Oakl<strong>and</strong> University, Rochester, MI<br />
Joyce Perkins, RN, PhD Augsburg College, Department of <strong>Nursing</strong> <strong>and</strong><br />
the Mayo Clinic, Rochester, MN<br />
Marguerite Purnell, RN, PhD, AHN-BC Associate Professor, The Christine E.<br />
Lynn College of <strong>Nursing</strong>, Florida Atlantic University, Boca Raton, FL<br />
Mary Pat Rapp, RN, PhD School of <strong>Nursing</strong>, University of Texas Health<br />
<strong>Science</strong> Center at Houston, Houston, TX<br />
Marilyn A. Ray, RN, PhD, CTN-A Professor Emeritus, The Christine E.<br />
Lynn College of <strong>Nursing</strong>, Florida Atlantic University, Boca Raton, FL<br />
Pamela Reed, RN, PhD, FAAN Associate Dean, University of Arizona,<br />
Tucson, AZ<br />
Francelyn M. Reeder, CNM, PhD Associate Professor Emeritus, University<br />
of Colorado Anschutz Medical Campus, College of <strong>Nursing</strong>, Aurora, CO<br />
Nancy Shirley, RN, PhD Associate Professor, Creighton University,<br />
Omaha, NE
xviii<br />
contributors<br />
Marlaine Smith, RN, PhD, FAAN Professor, Associate Dean, <strong>and</strong> Helen K.<br />
Persson Eminent Scholar, The Christine E. Lynn College of <strong>Nursing</strong>,<br />
Florida Atlantic University, Boca Raton, FL<br />
Mary Jane Smith, RN, PhD Professor <strong>and</strong> Associate Dean Graduate<br />
Affairs, University of West Virginia, School of <strong>Nursing</strong>, Morgantown, WV<br />
Todd Swinderman, RN, DNS, PhD Quality Coordinator, North Florida<br />
Regional Healthcare, Gainesville, FL<br />
Tetsuya Tanioka, RN, PhD Professor, University of Tokushima, Japan<br />
Stefan Topolski, MD Assistant Professor, University of Massachusetts,<br />
School of Medicine, Boston, MA; Clinical Instructor, University of<br />
New Engl<strong>and</strong>, <strong>and</strong> Founder <strong>and</strong> Director of <strong>Caring</strong> in Community, Inc.,<br />
Shelbourne, MA<br />
Marian C. Turkel, RN, PhD, NEA-BC Director of Professional <strong>Nursing</strong><br />
Practice, Albert Einstein Healthcare Network, Philadelphia, PA<br />
Michael Brooks Turkel, MBA Chief Executive Officer, Chestnut Hill<br />
Hospital, Philadelphia, PA<br />
Kathleen Valentine, RN, PhD Associate in Center Administration,<br />
The Christine E. Lynn College of <strong>Nursing</strong>, Florida Atlantic University,<br />
Boca Raton, FL<br />
Robin Vallacher, PhD Professor, Center for Complex Systems <strong>and</strong><br />
Brain <strong>Science</strong>s, Florida Atlantic University, Boca Raton, FL<br />
Jean Watson, PhD, RN, AHN-BC, FAAN Distinguished Professor<br />
of <strong>Nursing</strong>, Endowed Chair in <strong>Caring</strong> <strong>Science</strong>, University of Colorado,<br />
Anschutz Medical Campus, College of <strong>Nursing</strong>, Aurora, CO. Founder<br />
of Watson <strong>Caring</strong> <strong>Science</strong> Institute, Boulder, CO<br />
Bruce J. West, PhD Chair Army ST Corps, ST/Chief Scientist Mathematics,<br />
Information <strong>Science</strong>s Directorate, US Army Research Office,<br />
Research Triangle Park, NC
<strong>For</strong>eword<br />
T<br />
his book asks: “What can science say about the complex task of nursing?”<br />
One of the remarkable advances in science in the last few decades<br />
is the opportunity to address questions that previously were inaccessible to<br />
scientific inquiry. Traditionally, science organized itself around questions that<br />
could be answered. Increasingly, we ask the questions we want to answer<br />
about the world around us.<br />
I have been privileged to participate in developing <strong>and</strong> applying new<br />
methods of science that can better satisfy our desire to know <strong>and</strong> underst<strong>and</strong><br />
the world around us. Fifteen years ago, I offered a course at Boston<br />
University on the fundamental science of complex systems. Among my students<br />
was Professor Alice W. Davidson. Of this mathematical treatment of<br />
complex systems theories, Alice dem<strong>and</strong>ed insight <strong>and</strong> application to realworld<br />
problems of nursing. In parallel with the course activities, she performed<br />
research on the complexity of elderly living environments, eventually<br />
publishing a paper that validated the abstract theoretical underst<strong>and</strong>ing of<br />
complexity in this real-world context (Davidson, Teicher, & Bar-Yam, 1997).<br />
<strong>Complexity</strong> is a real world property, which we all encounter whether we use<br />
quantitative definitions or not.<br />
Our ability to successfully engage with the world <strong>and</strong> our tasks within<br />
it depends on a reasonable matching of the complexity of our environments<br />
with our own complexity. The importance of this concept has increased as<br />
the complexity of our society has increased. Alice’s work has direct implications<br />
for the environments of our elderly individuals. Designing them carefully<br />
is necessary in order to enable them to be intellectually active <strong>and</strong> yet<br />
not overwhelmed.<br />
This demonstration has much broader implications across all domains<br />
of our existence. <strong>For</strong> this volume, the condition in which the nurse works,<br />
the complexity of his or her environment is similarly important to recognize,<br />
calibrate, <strong>and</strong> ensure. As I engaged in this concept <strong>and</strong> its applications in the<br />
15 years since Alice’s study, I have found the pervasive importance of this<br />
insight in the design of our environments, our organizations <strong>and</strong> those of our<br />
children <strong>and</strong> parents.<br />
Over the years, Alice continued to challenge me to make practical for<br />
nursing the formal <strong>and</strong> quantitative insights of complex systems research.<br />
xix
xx<br />
foreword<br />
Alice <strong>and</strong> her co-editors, Marilyn Ray <strong>and</strong> Marian Turkel, are pioneers in<br />
the insight that it is possible to bring science to address the most complex,<br />
personal, interpersonal, biological, <strong>and</strong> social conditions. Nurses help people<br />
under complex stresses, biologically, physically, <strong>and</strong> socially. Essential<br />
to future advances in this field is recognizing this complexity as well as the<br />
opportunities we have for deep underst<strong>and</strong>ing <strong>and</strong> insights. This volume<br />
illustrates the many opportunities for scientific study.<br />
It is difficult to write this foreward knowing that Alice will not be present<br />
in any of my future classes, though her contributions are surely always represented<br />
in the slides where I describe her findings.<br />
As the editors <strong>and</strong> authors clearly state, “nursing is about caring.” It is<br />
appropriate that the effort to bring complex systems science into nursing<br />
received such early attention. After all, it is complex systems science that<br />
provides a framework for thinking about relatedness <strong>and</strong> relationships, a<br />
concept diminished in traditional science. The example I often give of the<br />
lack of perspective on relationships <strong>and</strong> their importance is the traditional<br />
dictionary definition of mother: “A female parent.” The often-missing relational<br />
definition might be “What a child calls his or her female parent.” The<br />
difference is both simple <strong>and</strong> profound, with pervasive significance for our<br />
society.<br />
It should be clear that despite abstract concepts <strong>and</strong> formulations, underlying<br />
the effort of this book is a profound sense of relationship with those<br />
who need help, those we care for.<br />
Yaneer Bar-Yam<br />
New Engl<strong>and</strong> Complex Systems Institute<br />
Reference<br />
Davidson, A., Teicher, M. H., & Bar-Yam, Y. (1997). The role of environmental complexity<br />
in the well-being of the elderly. <strong>Complexity</strong> <strong>and</strong> Chaos in <strong>Nursing</strong>, 3, 5–12.
Reflection<br />
T<br />
his is a long overdue work by visionary scholars in complexity science:<br />
Dr. Alice W. Davidson (who sadly left this earth plane as this manuscript<br />
was being completed) <strong>and</strong> her beloved gifted colleagues, Dr. Marilyn (Dee)<br />
Ray <strong>and</strong> Dr. Marian Turkel, who serve as editors of a comprehensive project<br />
with outst<strong>and</strong>ingly diverse nursing, physician, science, <strong>and</strong> administrator<br />
authors. This contemporary <strong>and</strong> futuristic publication offers a special gift<br />
by integrating nursing science, caring science, unitary, <strong>and</strong> complexity<br />
science into a new whole, helping to uncover the effects of caring on nursing,<br />
complexity, <strong>and</strong> human environments. This work intersects with personal/<br />
professional practice, education, research, administration, <strong>and</strong> health care<br />
systems at all levels.<br />
It is an honor <strong>and</strong> privilege to endorse this critical work at this point<br />
in time. The developments <strong>and</strong> focus in this publication also pass the test<br />
of time. It brings us into a new era of human consciousness <strong>and</strong> the role<br />
<strong>and</strong> relevance of complexities <strong>and</strong> dynamics of human caring–healing environments<br />
in which we live <strong>and</strong> work <strong>and</strong> find our being <strong>and</strong> becoming as<br />
persons <strong>and</strong> as human systems.<br />
This collected, edited manuscript is a magnificent exemplar of the evolving<br />
work in caring science. It is a unique honor to have this work included in<br />
the Watson <strong>Caring</strong> <strong>Science</strong> Institute Library at Springer Publishing Company.<br />
The focus of this scholarship brings new meaning <strong>and</strong> depth of complexity<br />
science to caring science, to healing relationships <strong>and</strong> human healing<br />
systems. It brings entirely new dimensions to the phenomenon <strong>and</strong> overused<br />
mind-set of “quality.”<br />
When one falls into the depth of the scholarship in this emerging field,<br />
one is drawn into the ethic, the philosophical grounding of an emerging worldview,<br />
a cosmology that unites, connects, explains, <strong>and</strong> helps to order our very<br />
reality, our chaotic world. It offers a passionate new order of human evolution<br />
that embraces the paradox, the chaotic, the disorder, offering a new lens to<br />
underst<strong>and</strong>, to comprehend, to personalize, to professionalize, <strong>and</strong> to give scientific<br />
<strong>and</strong> wisdom insights into creative emergence for what might be called<br />
Ontological Development or Ontological Design programs, projects <strong>and</strong> purposive<br />
transformative practices that inform <strong>and</strong> authenticate human existence,<br />
human caring, <strong>and</strong> healing at the human relationship <strong>and</strong> environmental level.<br />
xxi
xxii<br />
reflection<br />
This manuscript combines an array of authors’ talents <strong>and</strong> perspectives<br />
in this growing field. Each chapter includes a scholarly response to further<br />
inform the ontological <strong>and</strong> epistemological underpinnings of this dynamic<br />
science, integrating the science of unitary human beings, complex caring<br />
<strong>and</strong> human inquiry, <strong>and</strong> the complexity of the dynamics of human caring.<br />
The multiple authors bring together <strong>and</strong> unify deep dimensions, which<br />
invite personal <strong>and</strong> professional reflective scholarship <strong>and</strong> philosophical <strong>and</strong><br />
theoretical integration that is combined into a new synthesis of underst<strong>and</strong>ing<br />
for nursing <strong>and</strong> health care.<br />
These diverse chapters <strong>and</strong> the multiple authors’ foci help one to grasp<br />
the relevance as well as the ironic complexity of disease, illness, <strong>and</strong> caring<br />
systems as well as treatment approaches projecting the reader into technological,<br />
electronic documentation, <strong>and</strong> the future of humanoid relationships<br />
in nursing <strong>and</strong> complexity science(s).<br />
Such a comprehensive collection of work in the field of a unitary model<br />
of complexity is a testimony to the importance of this work <strong>and</strong> how it both<br />
grounds <strong>and</strong> transcends conventional views of science <strong>and</strong> reality <strong>and</strong> opens<br />
up new horizons of unitary visions. This collected scholarship in this area<br />
will inform the personal/professional evolution of caring <strong>and</strong> nursing in this<br />
century <strong>and</strong> beyond, inviting new visions of the evolved human in the world<br />
of practice, education, research, administration, <strong>and</strong> clinical care. It is truly<br />
a visionary futuristic manifesto for this time in nursing <strong>and</strong> health sciences<br />
at all levels.<br />
Jean Watson, PhD, RN, AHN-BC, FAAN<br />
Distinguished Professor of <strong>Nursing</strong><br />
Endowed Chair in <strong>Caring</strong> <strong>Science</strong><br />
University of Colorado, Anschutz Medical Campus<br />
College of <strong>Nursing</strong><br />
Aurora, CO<br />
Founder, Watson <strong>Caring</strong> <strong>Science</strong> Institute<br />
Boulder, CO<br />
www.nursing.ucdenver.edu/caring<br />
www.watsoncaringscience.org
Prologue<br />
N<br />
ursing’s disciplinary focus is the relationship of caring within a mutual<br />
human–environment health experience for healing <strong>and</strong> well-being<br />
(Newman, Sime, & Corcorran-Perry, 1991; Newman, Smith, Pharris, & Jones,<br />
2008; Ray, 2010a, 2010b; Ray & Turkel, 2010; Turkel, Ray, & Kornblatt, in<br />
press; Watson, 2005, 2008). With over 150 years of caring science <strong>and</strong> concentrated<br />
research over the past 30 years in the scholarship of caring, we<br />
have much to build on. As such, two central perspectives are highlighted in<br />
this book: Nightingale’s (1859/1969, 1992, 2010b) conceptual system along<br />
with Watson (1985, 2005, 2008) <strong>and</strong> Ray’s (1981a, 1984, 1989, 2001, 2006,<br />
2010b) caring theories. Also described is a comparison of the caring theories,<br />
the science of unitary human beings (SUHB), <strong>and</strong> the philosophy<br />
of complexity sciences. Such views on caring, the SUHB, <strong>and</strong> complexity<br />
depict a new form of trans-theoretical convergence—with each philosophy,<br />
theory of nursing, <strong>and</strong> sciences of complexity considering the mutual processes<br />
of human–environment interaction. In nursing, of course, it was Nightingale<br />
(1859/1969) who first identified this perspective.<br />
This prologue thus underscores Nightingale’s (1859/1969, 1992) theory<br />
of nursing as a reparative process that facilitates knowledge of the integrality<br />
of the human–environment relationship. The SUHB of Rogers (1970,<br />
1990), emphasizing the continuous <strong>and</strong> emergent nature of the simultaneous<br />
human <strong>and</strong> environmental fields at any given point in space <strong>and</strong> time,<br />
is illuminated. Although there are a number of caring theories, for the<br />
purposes of this prologue, the caring sciences of Watson <strong>and</strong> Ray will be<br />
highlighted.<br />
Indeed, Watson’s (1985, 2005, 2008) transpersonal theory of caring,<br />
which centers on caring as a moral ideal, love, <strong>and</strong> harmony of body, mind,<br />
<strong>and</strong> spirit, is emphasized. Equally so is Ray’s theory of bureaucratic caring<br />
(1981a, 1984, 1989, 2006, 2010b) (Coffman, 2010; Ray & Turkel, 2010; Turkel,<br />
2007), which describes caring as the relationship between human <strong>and</strong> spiritual<br />
caring dimensions (spiritual, ethical, humanistic, social), <strong>and</strong> the organizational<br />
context of hospital health care systems (with its economic, political,<br />
technological, <strong>and</strong> legal caring dimensions).<br />
xxiii
xxiv<br />
prologue<br />
The trans-theoretical identification recognizes the commonalities of<br />
nursing’s philosophy <strong>and</strong> conceptual frameworks. The commonalities within<br />
nursing also show how the theories relate to the philosophy of the sciences<br />
of complexity, specifically paralleling the central tenets—unitary nature,<br />
connectedness, belongingness, relationship, mutual human– environment<br />
process, energy, pattern, increasing complexity, nonrepeatable phenomena,<br />
self-organization, choice, <strong>and</strong> transformation (Anderson, Crabtree, Steele, &<br />
McDaniel, 2005; Davidson & Ray, 1991; Davidson, Ray, Cortes, Conboy, &<br />
Norman, 2006; Davidson, Teicher, & Bar-Yam, 1997; Hamilton, Pollack,<br />
Mitchell, Vicenzi, & West, 1997; Lindberg, Nash, & Lindberg, 2008; Ray, 1994,<br />
1998, 2006; Smith, 1999; Vicenzi, White, & Begun, 1997; Watson, 2005, 2008;<br />
Watson & Smith, 2002). Unlike complexity sciences, caring sciences focus on<br />
the uniqueness of the mutual human–environment relational caring process,<br />
which articulates the depth of meaning of caring within the human health<br />
experience from empirical, ethical, aesthetic, personal, <strong>and</strong> sociocultural patterning<br />
(Carper, 1978; Ray, 2010a; White, 1995). The following is a presentation<br />
of the nature of caring in nursing, Rogers’ <strong>Science</strong> of Unitary <strong>Human</strong><br />
Beings, <strong>and</strong> complexity sciences <strong>and</strong> nursing.<br />
The Nature of <strong>Caring</strong><br />
<strong>Caring</strong> is holistic <strong>and</strong> is the essence of nursing. Nurses <strong>and</strong> health care<br />
administrators in complex organizations recognize that caring, in the human<br />
health experience, facilitates excellence in nursing care, health care delivery,<br />
<strong>and</strong> patient outcomes. <strong>Caring</strong> is not only humanistic, spiritual, <strong>and</strong> an ethical<br />
phenomenon, but it integrates knowledge of the sociocultural environment,<br />
the technological, economic, political, <strong>and</strong> legal dimensions into its meaning<br />
structure <strong>and</strong> conceptual foundation. <strong>Caring</strong>, as complex, captures the genuine<br />
science of quality because its science is also the art of practice, an aesthetic<br />
which illuminates the beauty of the dynamic nurse–patient relationship, that<br />
makes possible authentic spiritual–ethical choices for transformation—healing,<br />
health, well-being, <strong>and</strong> a peaceful death. Thus, caring is universal <strong>and</strong> particular,<br />
ubiquitous in its appeal as the core of nursing philosophy, <strong>and</strong> particular<br />
in its diversity of expression in nursing practice.<br />
Contemporary nursing practice focuses on creating caring environments<br />
for nurses, patients, <strong>and</strong> families within today’s complex health care organizations.<br />
With the emergence of the American Nurses Credentialing Center’s<br />
(ANCC) Magnet Recognition Program ® (Magnet), nursing theory has moved<br />
from its central place in academia <strong>and</strong> research to practice. The majority of<br />
Magnet hospitals have implemented a theoretical framework grounded in<br />
caring science. The theme for the 2010 ANCC National Magnet Conference is<br />
“Magnet: A Culture of <strong>Caring</strong>.” Watson’s (1985, 2005, 2008) theory of human
PROLOGUE xxv<br />
caring has become the theory of choice as direct care registered nurses (RNs)<br />
return to caring values. Theory-guided practice advances both the discipline<br />
<strong>and</strong> profession of nursing. Practice outcomes demonstrate the creation of a<br />
caring-healing environment, at all levels, <strong>and</strong> facilitate both human <strong>and</strong> environmental<br />
well-being (Ray 1981a, 2010b; Turkel & Ray, 2004; Watson, 2008).<br />
Theoretical Exemplars of <strong>Caring</strong> <strong>Science</strong><br />
<strong>and</strong> the Mutual <strong>Human</strong>–Environment Process<br />
Nightingale (1859/1969, 1992) is credited as the “mother” of professional<br />
nursing. She laid the foundation for caring as central to nursing. Early in her<br />
life, Nightingale was concerned about others’ suffering, especially from her<br />
vantage point of considerable means. She was a deeply religious woman <strong>and</strong><br />
believed that God called her to help others <strong>and</strong> to practice the art of charity,<br />
love of one’s fellow man (human), <strong>and</strong> a faith in God (Calabria & Macrae,<br />
1994). Nightingale’s vision of nursing was seeing nurse caring actions as<br />
improving health through the reparative process of disease (dis-ease), which<br />
nature instituted (whom she articulated as God) within the human–environment<br />
relationship. Her work was not only influenced by her deep faith, but<br />
also by what she had experienced while traveling, training, <strong>and</strong> caring for<br />
wounded soldiers during the Crimean War. Nightingale was concerned about<br />
the human–environment relationship for enhancing healing <strong>and</strong> well-being.<br />
<strong>Nursing</strong> was not only the administration of medications <strong>and</strong> dressings, but<br />
also the proper use of fresh air, light, warmth, cleanliness, quiet, punctuality,<br />
<strong>and</strong> care, <strong>and</strong> the extreme importance of nursing in determining the<br />
issue of disease . . . “all at the least expense of vital power of the patient”<br />
(Nightingale, 1992, p. 6). Many of Nightingale’s ideas parallel the ways of<br />
thought <strong>and</strong> action present in nursing today. As such, Nightingale (Ray, 2010a)<br />
demonstrated the importance of nursing as nature <strong>and</strong> nurture in caring<br />
<strong>and</strong> health; the relationship among theology, spirituality, science, nature,<br />
environment, human action, <strong>and</strong> morals (ethics); the dynamic process of the<br />
nurse–patient caring relationship; the nurse as epidemiologist; employing<br />
evidence-based practice (from a knowledge of empirics <strong>and</strong> quantitative<br />
statistics); <strong>and</strong> nursing as open to interdisciplinary <strong>and</strong> cross-cultural practices.<br />
Thus, the importance of the human–environment caring relationship for<br />
health <strong>and</strong> well-being was born.<br />
Rogers’ (1970) nursing science is a unique conceptual system with its<br />
origin in the unitary nature of the human–environment mutual process for<br />
healing <strong>and</strong> health. Rogers’ (1970) conceptual system is scientific, a synthesis<br />
of ideas <strong>and</strong> facts, <strong>and</strong> creative—as it describes an irreducible whole, the<br />
SUHB. Over many years, Rogers (1970, 1990) identified homeodynamic principles<br />
<strong>and</strong> finally established the concepts of resonancy, helicy, <strong>and</strong> integrality
xxvi<br />
prologue<br />
to facilitate underst<strong>and</strong>ing <strong>and</strong> study of the continuous mutual human–<br />
environment process. Resonancy refers to continuous change in wave<br />
patterns in human <strong>and</strong> environmental fields, helicy is the continuous innovative,<br />
unpredictable, <strong>and</strong> increasing diversity of human <strong>and</strong> environmental field<br />
patterns, <strong>and</strong> integrality refers to the continuous mutual human field <strong>and</strong><br />
environmental field process (Rogers, 1990).<br />
While Rogers’ theory did not identify directly with complexity sciences,<br />
for example, the subsets of quantum theory, chaos theory, or the theory of<br />
complex adaptive systems, her vision was synchronous with many concepts<br />
common to complexity sciences (Briggs & Peat, 1989; Peat, 2002): evolving<br />
dynamic irreducible, nonrepeatable <strong>and</strong> nonlinear processes, wave patterning,<br />
energy fields, increasing complexity, greater diversity, timelessness, facets<br />
(suggests fractal patterns or ubiquitous wholes that are self-similar), <strong>and</strong><br />
emergence (Reeder, 1984; Rogers, 1970, 1990). The implicit SUHB philosophy<br />
always begins with the unitary nature of the human <strong>and</strong> environment<br />
in mutual process, which is continually open <strong>and</strong> emergent. Thus, locality<br />
<strong>and</strong> space <strong>and</strong> time properties are not absolute <strong>and</strong> emerge anywhere. This<br />
idea shows the unpredictable, increasingly diverse, <strong>and</strong> emergent patterning<br />
that becomes manifest as humans <strong>and</strong> the environment dynamically evolve.<br />
This patterning unfolds in nursing within the nurse–patient relationship,<br />
the unitary nature, <strong>and</strong> increasing complexity of the mutual human <strong>and</strong><br />
environment field process.<br />
Although Rogers viewed caring as important within nursing, she did not<br />
embrace it as a substantive area (Smith, 1999; Watson & Smith, 2002). She<br />
did, however, embrace the notion of unconditional love, not as a substantive<br />
area of study, but as critical to nursing practice. In the Rogerian sense, love is<br />
considered a unitary, irreducible mutual human-environmental energy field<br />
process (Rogers, 1990; Smith, 1999). As Rogers <strong>and</strong> others engaged with the<br />
study of the SUHB were advancing their ideas of the unitary nature of the<br />
mutual human-environment process, scholars in the caring sciences were<br />
philosophizing about the nature of caring as love <strong>and</strong> a human <strong>and</strong> spiritual<br />
connectedness. The religious or divine interconnectedness of caring, the caring<br />
consciousness of nurses (caritas or charity <strong>and</strong> compassion <strong>and</strong> loving<br />
kindness) can be understood as a higher human-environmental field process<br />
(Ray, 1981b, 1997, 2010a, 2010b; Smith, 1999; Watson, 2005, 2008; Watson &<br />
Smith, 2002).<br />
Smith (1999) wrote an extensive comparison <strong>and</strong> contrasting of the<br />
SUHB <strong>and</strong> caring, <strong>and</strong> identified patterns of caring meanings that are both<br />
implicit <strong>and</strong> explicit in the SUHB, such as (a) manifesting intentions (creating,<br />
holding, <strong>and</strong> expressing thoughts <strong>and</strong> will for caring–healing <strong>and</strong> well-being)<br />
(Purnell, 2006; Reeder, 1984); (b) appreciating pattern (the discovery of<br />
knowing wholeness <strong>and</strong> essence) (Cowling & Repede, 2010); (c) placing<br />
value on the other as lovable or worthy of being loved; (d) acknowledging
PROLOGUE xxvii<br />
the emergence of pattern (Ray, 1997, 2010a); (e) attuning to dynamic flow,<br />
for example, attuning to the rhythmic dance within the continuous mutual<br />
process—being present in the moment (Boykin & Schoenhofer, 2001)<br />
or in the caring science of Watson (1985, 2005, 2008), the caring moment;<br />
(f) experiencing the infinite or the p<strong>and</strong>imensional awareness of the coextensiveness<br />
of the universe within the context of human relating (Ray, 1997;<br />
Watson, 2005, 2008); <strong>and</strong> (g) inviting creative emergence or reflection of the<br />
transformative potential of caring for self <strong>and</strong> other <strong>and</strong> the belief in the continuing<br />
innovation of emergent patterning <strong>and</strong> the panorama of possibilities<br />
(Davidson & Ray, 1991; Davidson et al., 1997, 2006; Ray, 1998; Smith, 1999).<br />
From a trans-theoretical viewpoint, a human being is a caring energy field<br />
with information rooted in the body, interacting with the caring energy <strong>and</strong><br />
information of others <strong>and</strong> the universe (Cannato, 2010).<br />
Watson’s (1979, 1985, 2005, 2008) philosophy brought to light caring science<br />
as the essence of nursing <strong>and</strong> as the foundational core of the discipline.<br />
<strong>Caring</strong> is a dynamic transpersonal relationship between the nurse <strong>and</strong> the<br />
patient that involves ethical choice <strong>and</strong> action within the present moment (past,<br />
future, <strong>and</strong> present all at once), which manifests the potential for harmony of<br />
body, mind, <strong>and</strong> soul (spirit) (Watson, 1985, 2005, 2008). Thus, the process<br />
of caring is a moral ideal committed to a specific end, “. . . the protection,<br />
enhancement, <strong>and</strong> preservation of the person’s humanity which helps to restore<br />
inner harmony <strong>and</strong> potential healing” (Watson, 1985, p. 58). <strong>Caring</strong> consists of<br />
the 10 caritas processes, or caring practices as they have been referred to by<br />
RNs in the practice setting, <strong>and</strong> are known to facilitate healing. Caritas nursing<br />
practice involves working from a human-to-human connection, a practice that<br />
is “heart-centered.” Watson’s (2008) caritas processes are exemplars of caring<br />
science. Watson’s theory continues to be advanced in the practice setting as<br />
RNs transform from a focus on the tasks of nursing to “the practice of loving<br />
kindness, authentic presence, cultivation of one’s spiritual practices, <strong>and</strong> being<br />
in the caring–healing environment <strong>and</strong> allowing for miracles” (Watson, 2008,<br />
p. 34). Watson’s philosophy <strong>and</strong> research reveals that we must become increasingly<br />
aware of who we are, the nature of <strong>and</strong> mystery of caring, <strong>and</strong> how we<br />
influence others <strong>and</strong> the environment in terms of the choices made for caring,<br />
which is life giving for all.<br />
Watson’s Caritas Processes<br />
The 10 caritas processes grounded in the tenets of philosophy <strong>and</strong> ethics<br />
potentiate the creation of a caring–healing environment for nurses, patients,<br />
<strong>and</strong> families. RNs from various practice settings developed the caritas literacy,<br />
where various attributes of the caritas processes were identified <strong>and</strong><br />
inform the profession of nursing. A brief overview follows.
xxviii<br />
prologue<br />
Caritas Process 1: Cultivating the Practice of Loving Kindness <strong>and</strong><br />
Equanimity Toward Self <strong>and</strong> Others involves listening <strong>and</strong> respecting others,<br />
honoring human dignity, treating self <strong>and</strong> others with loving kindness,<br />
recognizing vulnerabilities in self <strong>and</strong> others, <strong>and</strong> accepting self <strong>and</strong> others<br />
as they are.<br />
Caritas Process 2: Being Authentically Present: Enabling, Sustaining,<br />
<strong>and</strong> Honoring the Faith, Hope <strong>and</strong> Deep Belief System <strong>and</strong> the Inner-<br />
Subjective Life World of Self <strong>and</strong> Others means creating opportunities for<br />
reflection, silence, <strong>and</strong> pause; promoting intentionality <strong>and</strong> human connections<br />
with others viewing life as a mystery to be explored rather than a problem<br />
to be solved; <strong>and</strong> interacting with caring arts <strong>and</strong> sciences to promote<br />
healing <strong>and</strong> wholeness.<br />
Caritas Process 3: Cultivation of One’s Own Spiritual Practices <strong>and</strong><br />
Transpersonal Self, Going Beyond Ego-Self means practicing self-reflection,<br />
transforming tasks into caring–healing interactions, demonstrating genuine<br />
interest in others, <strong>and</strong> valuing the goodness of self <strong>and</strong> others as human beings.<br />
Caritas Process 4: Developing <strong>and</strong> Sustaining a Helping-Trusting <strong>Caring</strong><br />
Relationship includes the concept of a caring moment where the experience<br />
transforms both nurse <strong>and</strong> patient. This involves the practice of authentic<br />
presence, holding a sacred space for healing in others’ time of need, <strong>and</strong><br />
entering into the experience to explore the possibilities in the moment <strong>and</strong><br />
in the relationship.<br />
Caritas Process 5: Being Present To <strong>and</strong> Supporting the Expressions of<br />
Positive <strong>and</strong> Negative Feelings means creating <strong>and</strong> holding sacred space<br />
(a safe space for unfolding <strong>and</strong> emerging); encouraging story telling as a way<br />
to express underst<strong>and</strong>ing, allowing the story to emerge, change, <strong>and</strong> grow;<br />
<strong>and</strong> encouraging reflections of experiences <strong>and</strong> feelings.<br />
Caritas Process 6: Creative Use of Self <strong>and</strong> All Ways of Knowing as Part<br />
of the Caritas Process: Engage in the Art of Caritas <strong>Nursing</strong>. In practice, a<br />
caritas nurse uses self to create healing environments via intentional touch,<br />
artistic expression, journaling, music, <strong>and</strong> play; integrates aesthetic, empirical,<br />
ethical, personal, <strong>and</strong> metaphysical ways of knowing into practice; <strong>and</strong><br />
helps others to find new meaning in their journey.<br />
Caritas Process 7: Engage in Genuine Teaching-Learning Experience that<br />
Attends to the Unity of Being <strong>and</strong> Subjective Meaning Attempting to Stay Within<br />
the Other’s Frame of Reference. In nursing practice, these calls for a focus on<br />
honoring the wholeness of persons, giving information to someone in a way<br />
they can receive it, seeking to learn from others <strong>and</strong> underst<strong>and</strong> their world<br />
view, <strong>and</strong> helping others underst<strong>and</strong> how they are thinking about their health.<br />
Caritas Process 8: Creating a Healing Environment at All Levels. A caritas<br />
nurse creates space for: human connections to occur, caring intentions, <strong>and</strong> a<br />
healing environment by attending to nursing as environment, light, art, water<br />
noise, h<strong>and</strong> washing, <strong>and</strong> comfort measures.
PROLOGUE xxix<br />
Caritas Process 9: Administering Sacred <strong>Nursing</strong> Acts of <strong>Caring</strong>-Healing<br />
by Tending to Basic <strong>Human</strong> Needs. In practice this means seeing the wholeness<br />
of the patient, respecting patients’ special needs, involving the family<br />
or significant other in the plan of care, <strong>and</strong> transforming the tasks of nursing<br />
into sacred acts of love <strong>and</strong> caring.<br />
Caritas Process 10: Opening <strong>and</strong> Attending to Spiritual/Mysterious <strong>and</strong><br />
Existential Unknowns of Life-Death or Allowing for Miracles. This is often<br />
difficult to grasp or explain. The caritas nurse is comfortable dealing with the<br />
unknown, being open to possibilities, <strong>and</strong> nurturing <strong>and</strong> supporting.<br />
As RNs are returning to acknowledging the humanity of nursing through<br />
caring practices, health care is transforming <strong>and</strong> new visions for the future<br />
are being cocreated. As Watson’s caring science continues to transform<br />
practice <strong>and</strong> the system, traditional outcome measures will not capture the<br />
essence of caring moments or allow for miracles. However, the emergence<br />
of new <strong>and</strong> innovative approaches to measure success or outcomes, such as<br />
human flourishing, purposeful involvement, <strong>and</strong> building capacity will occur.<br />
Watson (2008) remarked, “A <strong>Caring</strong> <strong>Science</strong>/Caritas orientation to nursing<br />
education intersects with the arts <strong>and</strong> humanities <strong>and</strong> related fields of<br />
study, beyond the conventional clinicalized <strong>and</strong> medicalized views of human<br />
<strong>and</strong> health-healing” (p. 255). Therefore, to facilitate successful health <strong>and</strong><br />
healing outcomes, <strong>and</strong> to advance our knowledge of what it means to be<br />
human, Watson (2008) spoke about the importance of advancing caritas education<br />
in all arenas. Watson emphasized that a caring science “engages with<br />
the diversity of the sciences <strong>and</strong> humanities <strong>and</strong> the notions of personal<br />
growth, of transformative learning by which the terms in which people think<br />
<strong>and</strong> the words they speak can actually be changed in educative situations”<br />
(p. 258). By engaging Watson’s caring science as caritas (love, ethics, mystery,<br />
transcendence) with, for example, the SUHB, <strong>and</strong> Ray’s theory of bureaucratic<br />
caring (highlighting organizations <strong>and</strong> caring), <strong>and</strong> the philosophy <strong>and</strong><br />
research of the sciences of complexity (interconnectedness, self-organization,<br />
emergence), a greater underst<strong>and</strong>ing of science <strong>and</strong> the arts will emerge<br />
that will, in effect, change the world from disengagement, competition, <strong>and</strong><br />
violence to compassion, justice, <strong>and</strong> peace.<br />
Ray’s Theory of Bureaucratic <strong>Caring</strong><br />
Ray’s (1981a, 1984, 1989, 2006, 2010a, 2010b; Coffman, 2006, 2010; Ray &<br />
Turkel, 2010; Turkel, 2001, 2006, 2007) theory of bureaucratic caring helps us<br />
to see how we can look at complex health care, community, <strong>and</strong> global systems<br />
so that the caritas processes that Watson (2008) articulates can be more<br />
understood <strong>and</strong> better implemented in practice. Health care organizations are<br />
hierarchical <strong>and</strong> exhibit leadership <strong>and</strong> management system processes that
xxx<br />
prologue<br />
manifest some degree of power, authority, <strong>and</strong> control for effective functioning.<br />
Hospitals therefore tend to be bureaucratic; that is, they are not only places for<br />
the care of the sick, but they also are integrated technical-politico-economic<br />
<strong>and</strong> legal organizations. These contextual patterns serve to facilitate efficient<br />
<strong>and</strong> effective functioning of the system. Although new approaches to leadership<br />
have been proposed, such as self-governing systems more often than<br />
not, workplace communities survive because of knowledge of their economic,<br />
technical, legal <strong>and</strong> political integrative patterning. Thus, organizations are<br />
complex <strong>and</strong> dynamic cultural systems that people consciously developed<br />
for the purposes of coordinating activities for specific ends (Wheatley, 2006).<br />
In health care, these ends are an efficient organization <strong>and</strong> healthy patient<br />
outcomes.<br />
Organizations are small cultures. Cultures are co-created by people as they<br />
interact <strong>and</strong> construct meaning from diverse or common values, beliefs, attitudes,<br />
<strong>and</strong> behaviors that are communicated <strong>and</strong> transmitted from one group<br />
to another over time. Organizational cultures deal with values <strong>and</strong> beliefs about<br />
what they are there for, products they may produce, how they govern <strong>and</strong> manage,<br />
how they use technology, <strong>and</strong> how they deal with human relationships—<br />
employer–employee ideologies <strong>and</strong> social interactions (Bar-Yam, 2004; Perrow,<br />
1986). As such, organizations as small cultures include most social structural<br />
elements that are visible in society, such as human systems, political, economic,<br />
technical, legal, ethical, religious/spiritual, <strong>and</strong> educational systems. Thus,<br />
highly concentrated organizational cultures are woven into meaningful dimensions<br />
of the social structure in order to make sense out of what occurs among<br />
people <strong>and</strong> professions in a given system. Today, organizational cultures comprises<br />
patterns of behavior, social norms, complex adaptive systems, creative<br />
ideas, complex problem-solving processes, explanatory models, <strong>and</strong> action,<br />
including spiritual–ethical caring action (Bar-Yam, 2004; Ray, 2010).<br />
To more fully underst<strong>and</strong> the theory of bureaucratic caring, it is necessary<br />
to underst<strong>and</strong> the nature of bureaucracy as it relates to the theory. Developed<br />
over many centuries of Western civilization, complex organizations were recognized<br />
as rational–legal forms of bureaucracy, with a bureaucratic model<br />
finally identified by Max Weber in 1947 (Boone & Bowen, 1980). The process<br />
acknowledged key elements of a rational–legal system that included the<br />
major areas <strong>and</strong> tools of economic, political, social, technological, <strong>and</strong> legal<br />
dimensions that we recognize in complex systems today. Within a bureaucracy<br />
(organizational culture), diverse people cocreate <strong>and</strong> construct the<br />
meaning of their complex <strong>and</strong> dynamic social reality through social interaction.<br />
Within a bureaucracy, the interplay of communication <strong>and</strong> ethical choice<br />
making within relationships form a moral community within the workplace<br />
community; this social interaction sets the moral tone of the work life environment<br />
(Turkel & Ray, 2000, 2001, 2004, 2009). Bureaucracy, thus, is a<br />
social tool that identifies the dynamics of relational authority, power, control,
PROLOGUE xxxi<br />
<strong>and</strong> ethical behavior that has an influence on what we value <strong>and</strong> how we<br />
think <strong>and</strong> reason in work life interactions (Perrow, 1986).<br />
Ray’s (1981a, 1984, 1989, 2006, 2010a, 2010b; Coffman, 2010; Turkel,<br />
2001, 2006, 2007) theory of bureaucratic caring emerged from studying the<br />
meaning of caring in a hospital’s the complex institutional culture. As a central<br />
focus of the discipline of nursing (Newman et al., 2008; Ray, 1981a,<br />
1981b; Watson, 1979, 1985, 2005, 2008), caring “unfolds within a participative<br />
process formed by the informational patterns of the nurse <strong>and</strong> the<br />
patient” (Newman et al., 2008, p. 4). Thus, the sphere of knowledge in<br />
nursing captures views of caring, copresence, wholeness (health <strong>and</strong> wellbeing—integration<br />
of body, mind, spirit), choice, <strong>and</strong> emergence in the<br />
human–environment relationship.<br />
Through her research, Ray (1981a, 1984, 1989, 2006, 2010a, 2010b;<br />
Coffman, 2010; Ray & Turkel, 2010) also discovered how the context itself<br />
(the bureaucracy) played a role in the meaning structure of caring, identifying<br />
both substantive <strong>and</strong> formal theories, differential caring <strong>and</strong> a synthesis,<br />
bureaucratic caring. The theory is holographic (Coffman, 2010; Ray, 2006,<br />
2010a; Ray & Turkel, 2010). <strong>Caring</strong> is a whole, yet is a part of the complexity<br />
of a hospital, <strong>and</strong> in essence, the society at large. Within the differential<br />
caring theory, caring in the complex organization of the hospital differentiated<br />
itself in terms of meaning by its unit context—dominant caring dimensions<br />
related to areas of practice or units wherein professionals worked <strong>and</strong><br />
patients resided.<br />
Differential caring theory also showed that different units espoused different<br />
(dominant) caring meanings based on their organizational goals <strong>and</strong><br />
values, such as technological caring in intensive care units or surgical suites,<br />
humanistic <strong>and</strong> spiritual caring in the oncology unit, <strong>and</strong> legal, economic,<br />
<strong>and</strong> political caring in the administrative environments (Ray, 2006; Ray &<br />
Turkel, 2010).<br />
In this light, differential caring was organized into a hierarchical structure<br />
(psychological, practical, interactional, philosophic) from data on the<br />
meaning of caring (Ray, 1981a, 1984, 2010b). Here, the data revealed that<br />
differential caring theory is an expression of beliefs <strong>and</strong> behaviors relating<br />
to competing technological, ethical, religious, political, legal, economic,<br />
educational, humanistic, <strong>and</strong> social factors of the organization <strong>and</strong> dominant<br />
culture.<br />
<strong>For</strong> its part, the formal theory of bureaucratic caring emerged by integrating<br />
the qualitative data from interviews, participant–observations of the hospital<br />
culture, <strong>and</strong> the interpretation of meaning of caring using an Hegelian<br />
philosophy of thesis, antithesis, synthesis: illuminating the thesis of caring<br />
(a meaning system) in relation to the potential antithesis of caring (the<br />
hospital as a bureaucracy) to a synthesis, the theory of bureaucratic caring.<br />
The theory illuminates the nature of caring as the integration of humanistic,
xxxii<br />
prologue<br />
social, ethical, religious/spiritual, political, economic, technological, <strong>and</strong> legal<br />
caring. By researching <strong>and</strong> underst<strong>and</strong>ing the meaning of caring, nurses <strong>and</strong><br />
other professionals showed the uniqueness of caring as an expression of the<br />
complex human-environment mutual process. To capture this uniqueness of<br />
caring within contemporary nursing practice in complex organizations, the<br />
nursing process has been reconceptualized with a new mnemonic: recognizing,<br />
connecting, partnering, <strong>and</strong> reflecting (RCPR) (Turkel & Ray, in press).<br />
<strong>Complexity</strong> <strong>Science</strong>s <strong>and</strong> <strong>Nursing</strong><br />
<strong>Complexity</strong> sciences, called the science of quality, look to networks of relationship<br />
as the underpinning for choices in the continual <strong>and</strong> emerging<br />
mutual human–environment process (Bar-Yam, 2004; Briggs & Peat, 1989;<br />
Peat, 2002). <strong>Complexity</strong> sciences also fit the ontology (what we know about<br />
being) <strong>and</strong> epistemology (the way we know) of nursing science (Anderson<br />
et al., 2005; Davidson & Ray, 1991; Davidson et al., 1997; Lindberg, Nash, &<br />
Lindberg, 2008; Ray, 1994, 1998). The mutual human–environment process<br />
for both complexity sciences <strong>and</strong> nursing science involves phenomena that<br />
are complex, dynamic, relational, nonlinear, structurally similar, integral,<br />
p<strong>and</strong>imensional, holonomic, difficult to study, qualitative, self-organizing,<br />
<strong>and</strong> open to emergence. The human–environment mutual process recognizes<br />
the unitary nature of the human <strong>and</strong> the environment—everything in<br />
the universe is interdependent; is sensitive to initial conditions (hysteresis);<br />
is patterned; evolves over space <strong>and</strong> time, is similar through constant change<br />
(homeodynamic) but never again exactly the same (irreversible); has “properties”<br />
that arise in the act of observation itself; has phenomena that are<br />
capable of filtration (choice) by involved agents-in-relationship; <strong>and</strong> has phenomena<br />
that self-organize (change or transform). Thus, there is continuous<br />
emergence (Bar-Yam, 2004; Briggs & Peat, 1989; Davidson & Ray, 1991; Peat,<br />
2002; Ray, 1994, 1998). In nursing science, the mutual process of humans<br />
<strong>and</strong> the environment evolves toward health, healing, or well-being through<br />
the caring relationship. This transformation is relational self-organization<br />
(Ray, 1994).<br />
<strong>Complexity</strong> sciences <strong>and</strong> nursing science have the power to promote a<br />
deeper underst<strong>and</strong>ing of human beings as they evolve with the environment.<br />
It is a symphony of mutual continuous change or transformation: “The complexity<br />
<strong>and</strong> the interdependency of agents who interact in a self-organizing<br />
manner make it impossible for any single agent to control the processes <strong>and</strong><br />
outcomes of care for any patient” (Wiggins, 2008, p. 11). However, relational<br />
caring self-organization in nursing exposes the power <strong>and</strong> energy of the caring<br />
relationship <strong>and</strong> the caring moment (Watson, 2008). Choice within networks<br />
of relationship or honoring the patient <strong>and</strong> family through caring cocreates a
PROLOGUE xxxiii<br />
living organization (Nirenberg, 1993) where “seeing” with the body, mind, <strong>and</strong><br />
soul (spirit <strong>and</strong> heart) symbolizes loving kindness, caring communication, <strong>and</strong><br />
mystery. There is a deep spiritual meaning to caring in the mutual human–<br />
environment process (Watson, 2008). In a world of many complex dimensions,<br />
the available information exceeds more than what our senses perceive.<br />
Choosing the best ethical <strong>and</strong> spiritual action is based on information<br />
gathered from the multidimensionality of patients’ <strong>and</strong> families’ clinical caring<br />
experiences by nurses <strong>and</strong> other professionals who have moral commitment<br />
<strong>and</strong> caring knowledge, <strong>and</strong> use their intuition (intention <strong>and</strong> practical wisdom)<br />
to cocreate change <strong>and</strong> relational self-organization. Intuition, which reflects<br />
the art of nursing, is a dimension of Watson’s (2008) theory of human caring<br />
as described in Caritas Process 6 (which calls for Creative Use of Self <strong>and</strong> All<br />
Ways of Knowing as Part of the Caritas Process: Engage in the Art of Caritas<br />
<strong>Nursing</strong>). This concept of intuition is nonlinear <strong>and</strong> requires the nurse to be<br />
open to innovation <strong>and</strong> creativity in nursing practice. As a complex human<br />
concept, intuition is one of the multiple ways of knowing that is acknowledged<br />
by a caring nurse as he/she comes to know <strong>and</strong> underst<strong>and</strong> self <strong>and</strong><br />
patient as a caring person.<br />
An Invitation<br />
The authors invite all who read this book to reflect on each chapter <strong>and</strong> the<br />
responses that follow each chapter. Here, reading requires an open mind, letting<br />
go of conventional ways of thinking, <strong>and</strong> a willingness to move beyond<br />
one’s comfort zone as one opens up to emerging possibilities. This book, a<br />
unique contribution to the discipline, is the first to focus on both caring science<br />
<strong>and</strong> complexity sciences within the realm of nursing science, practice,<br />
<strong>and</strong> health care organizations. The commonality between caring science <strong>and</strong><br />
complexity sciences is the human connection, the relationship, <strong>and</strong> the pattern<br />
recognition that facilitates underst<strong>and</strong>ing of the mutual human <strong>and</strong> environment<br />
process for emergence of health, healing, well-being, or a peaceful death.<br />
The vision for this book grew out of the commitment, passion, <strong>and</strong> dedication<br />
of the co-editors, the late Dr. Alice W. Davidson, one of the first nursing<br />
scholars to advance nursing <strong>and</strong> complexity sciences; Dr. Marilyn Ray, who<br />
integrated caring science <strong>and</strong> complexity sciences in contemporary nursing<br />
theory <strong>and</strong> health care practices; <strong>and</strong> Dr. Marian Turkel, who is committed<br />
to the teaching <strong>and</strong> implementation of caring science in complex health care<br />
systems <strong>and</strong> research initiatives.<br />
The chapters <strong>and</strong> responses with a variety of practice exemplars in this<br />
book describe, explicate, <strong>and</strong> reflect unique trans-theoretical approaches that<br />
converge tenets from the philosophies of caring sciences, the SUHB, <strong>and</strong><br />
complexity sciences. Scholars with knowledge related to caring science, the
xxxiv<br />
prologue<br />
SUHB, <strong>and</strong> complexity sciences contributed to this book. The chapters <strong>and</strong><br />
responses are diverse, illuminating the diversity of complexity itself, but similar<br />
in the underlying articulation of <strong>and</strong> need for human caring <strong>and</strong> concern<br />
for the delivery of quality health care. There are chapters more focused on<br />
complexity sciences, highlighting, for example, entropy, methods, organizational<br />
paradoxes, <strong>and</strong> conflict relationships from more theoretical, quantitative,<br />
<strong>and</strong>/or mathematical research approaches. There is a chapter focused<br />
on the disease process of diabetes that shows the complexity of diabetes<br />
from the cellular to policy levels. There are chapters focused on theoretical<br />
<strong>and</strong> qualitative research methods or newer research methods capturing the<br />
science of complexity, such as the comparing <strong>and</strong> contrasting of complexity<br />
sciences <strong>and</strong> the SUHB, complex caring dynamics, <strong>and</strong> story theory <strong>and</strong><br />
method. There are chapters related to leadership, caring in complex health<br />
care organizations, <strong>and</strong> nursing education that address both complexity <strong>and</strong><br />
caring sciences. And finally there are chapters that challenge our ethical<br />
thinking with informatics applications in practice, <strong>and</strong> the future of nursing<br />
<strong>and</strong> caring within the realm of the human–humanoid relationship.<br />
Each chapter begins with an introductory preface describing the relevance<br />
of the content to contemporary complexity science, nursing, <strong>and</strong> caring<br />
sciences for human–environment well-being. Each chapter has a response, <strong>and</strong><br />
sometimes two responses, that highlight what the particular chapter means<br />
to nursing education, research, leadership, administration, <strong>and</strong> practice.<br />
Responses provide the reader with a practical application or underst<strong>and</strong>ing of<br />
the content presented. Three types of responses were offered to the response<br />
authors: (a) a structured contextual template, (b) a response to open-ended<br />
questions, <strong>and</strong> (c) an open emergent <strong>and</strong> reflective process. Response authors<br />
chose what illuminated or critiqued ideas in the chapter <strong>and</strong> many offered<br />
new approaches based upon nursing research or clinical practice applications.<br />
Readers are invited to engage in personal reflection on the relevance<br />
of the writings as they relate to theory, research, education, leadership,<br />
<strong>and</strong> practice. The Epilogue <strong>and</strong> Addendum at the end of the book provide<br />
challenging questions <strong>and</strong> practical definitions of terms from nursing <strong>and</strong><br />
complexity sciences to further demonstrate how nurses, physicians, <strong>and</strong><br />
health care leaders can use or continue to embrace the use of caring in the<br />
mutual human–environment relationship in education, research, administration,<br />
leadership, <strong>and</strong> practice.<br />
References<br />
Anderson, R., Crabtree, B., Steele, D., & McDaniel, R., Jr. (2005). Case study research:<br />
The view from complexity science. Qualitative Health Research, 20(10), 1–17.<br />
Bar-Yam, Y. (2004). Making things work: Solving complex problems in a complex<br />
world. Boston: NECSI Knowledge Press.
PROLOGUE xxxv<br />
Boone, L., & Bowen, D. (1980). The great writings in management <strong>and</strong> organizational<br />
behavior. Tulsa, OK: Penn Well.<br />
Boykin, A., & Schoenhofer, S. (2001). <strong>Nursing</strong> as caring: A model for transforming<br />
practice (2nd ed.). Sudbury, MA: Jones & Bartlett.<br />
Briggs, J., & Peat, F. D. (1989). Turbulent mirror: An illustrated guide to chaos theory<br />
<strong>and</strong> the science of wholeness. New York: Harper & Row.<br />
Calabria, M., & Macrae, J. (Eds.). (1994). Suggestions for thought by Florence Nightingale:<br />
Selections <strong>and</strong> commentaries. Philadelphia: University of Pennsylvania Press.<br />
Cannato, J. (2010). Field of compassion: How the new cosmology is transforming spiritual<br />
life. Notre Dame, IN: Sorin Books.<br />
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in <strong>Nursing</strong><br />
<strong>Science</strong>, 1(1), 13–23.<br />
Coffman, S. (2006). Marilyn Anne Ray’s theory of bureaucratic caring. In A. Marriner<br />
Tomey & M. Alligood (Eds.), <strong>Nursing</strong> theorists <strong>and</strong> their work (6th ed., pp. 116–139).<br />
St. Louis, MO: Mosby/Elsevier.<br />
Coffman, S. (2010). Marilyn Anne Ray’s theory of bureaucratic caring. In M. Alligood &<br />
A. Marriner Tomey (Eds.), <strong>Nursing</strong> theorists <strong>and</strong> their work (7th ed., pp. 113–136).<br />
St. Louis, MO: Mosby/Elsevier.<br />
Cowling, R., & Repede, E. (2010). Unitary appreciative inquiry: Evolution <strong>and</strong> refinement.<br />
Advances in <strong>Nursing</strong> <strong>Science</strong>, 33(1), 64–77.<br />
Davidson, A., & Ray, M. (1991). Studying the human-environment phenomenon using<br />
the science of complexity. Advances in <strong>Nursing</strong> <strong>Science</strong>, 4(2), 73–87.<br />
Davidson, A., Ray, M., Cortes, S., Conboy, L., & Norman, M. (2006). <strong>Complexity</strong> for<br />
human-environment well-being. Retrieved December 2, 2009, from http://necs<br />
.org/events/iccs6/viewpaper:id=216<br />
Davidson, A., Teicher, M., & Bar-Yam, Y. (1997). The role of environmental complexity<br />
in the well-being of the elderly. <strong>Complexity</strong> <strong>and</strong> Chaos in <strong>Nursing</strong>, 3(1), 5–12.<br />
Hamilton, P., Pollack, J., Mitchell, D., Vicenzi, A., & West, B. (1997). The application<br />
of nonlinear dynamics in nursing research. Nonlinear Dynamics, Psychology, <strong>and</strong><br />
Life <strong>Science</strong>s, 1(4), 237–261.<br />
Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: <strong>Nursing</strong> in the age of complexity.<br />
Bordentown, NJ: Plexus Press.<br />
Newman, M., Sime, A., & Corcoran-Perry, S. (1991). The focus of the discipline of nursing.<br />
Advances in <strong>Nursing</strong> <strong>Science</strong>, 14(1), 1–6.<br />
Newman, M., Smith, M., Dexheimer-Pharris, M., & Jones, D. (2008). The focus of the<br />
discipline revisited. Advances in <strong>Nursing</strong> <strong>Science</strong>, 31(1), E16–E27. doi:10.1097/01<br />
.ans. 0000311533.65941.f1<br />
Nightingale, F. (1859/1969). Notes on nursing: What it is <strong>and</strong> what it is not. New York:<br />
Dover.<br />
Nightingale, F. (1992). Notes on nursing: What it is <strong>and</strong> what it is not. Philadelphia:<br />
J. B. Lippincott.<br />
Nirenberg, J. (1993). The living organization. San Diego, CA: Pfeiffer & Company.<br />
Peat, F. D. (2002). From certainty to uncertainty: The story of science <strong>and</strong> ideas in the<br />
twentieth century. Washington, DC: Joseph Henry Press.<br />
Perrow, C. (1986). Complex organizations: A critical essay. New York: McGraw-Hill.<br />
Purnell, M. (2006). Development of a caring model for nursing education. International<br />
Journal for <strong>Human</strong> <strong>Caring</strong>, 10(3), 8–16.
xxxvi<br />
prologue<br />
Ray, M. (1981a). A study of caring within the institutional culture. Unpublished doctoral<br />
dissertation, University of Utah, Salt Lake City, UT.<br />
Ray, M. (1981b). A philosophical analysis of caring within nursing. In M. Leininger<br />
(Ed.), <strong>Caring</strong>: An essential human need (pp. 25–36). Thorofare, NJ: Charles B.<br />
Slack.<br />
Ray, M. (1984). The development of a nursing classification system of caring. In<br />
M. Leininger (Ed.), Care, the essence of nursing <strong>and</strong> health (pp. 93–112). Thorofare,<br />
NJ: Charles B. Slack.<br />
Ray, M. (1989). The theory of bureaucratic caring for nursing practice in the organizational<br />
culture. <strong>Nursing</strong> Administration Quarterly, 13(2), 31–42.<br />
Ray, M. (1994). Complex caring dynamics: A unifying model of nursing inquiry.<br />
Theoretic <strong>and</strong> Applied Chaos in <strong>Nursing</strong>, 1(1), 23–32.<br />
Ray, M. (1997). Illuminating the meaning of caring: Unfolding the sacred art of divine<br />
love. In M. Roach (Ed.), <strong>Caring</strong> from the heart: The convergence of caring <strong>and</strong><br />
spirituality (pp. 163–178). New York: Paulist Press.<br />
Ray, M. (1998). <strong>Complexity</strong> <strong>and</strong> nursing science. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 11, 91–93.<br />
Ray, M. (2001). The theory of bureaucratic caring. In M. Parker (Ed.), <strong>Nursing</strong> theories<br />
<strong>and</strong> nursing practice (pp. 421–430). Philadelphia: F. A. Davis.<br />
Ray, M. (2006). The theory of bureaucratic caring. In M. Parker (Ed.), <strong>Nursing</strong> theories<br />
<strong>and</strong> nursing practice (2nd ed., pp. 360–368). Philadelphia: F. A. Davis.<br />
Ray, M. (2010a). Transcultural caring dynamics in nursing <strong>and</strong> health care.<br />
Philadelphia: F. A. Davis.<br />
Ray, M. (2010b). A study of caring within an institutional culture: The discovery of<br />
the theory of bureaucratic caring. Saabrücken, Germany: LAP Lambert Academic<br />
Publishing.<br />
Ray, M., & Turkel, M. (2010). The theory of bureaucratic caring. In M. Parker &<br />
M. Smith (Eds.), <strong>Nursing</strong> theories <strong>and</strong> nursing practice (3rd ed.). Philadelphia:<br />
F. A. Davis.<br />
Reeder, F. (1984). Philosophical issues in the Rogerian science of unitary human<br />
beings. Advances in <strong>Nursing</strong> <strong>Science</strong>, 8(1), 14–23.<br />
Rogers, M. (1970). An introduction to the theoretical basis of nursing. Philadelphia:<br />
F. A. Davis.<br />
Rogers, M. (1990). <strong>Nursing</strong>: <strong>Science</strong> of unitary, irreducible, human beings: Update<br />
1990. In E. Barrett (Ed.), Visions of Rogers’ science-based nursing (Publication No.<br />
15-2285). New York: National League for <strong>Nursing</strong>.<br />
Smith, M. (1999). <strong>Caring</strong> <strong>and</strong> science of unitary human beings. Advances in <strong>Nursing</strong><br />
<strong>Science</strong>, 21, 14–28.<br />
Turkel, M. (2001). Applicability of bureaucratic caring theory to contemporary nursing<br />
practice: The political <strong>and</strong> economic dimensions. In M. Parker (Ed.), <strong>Nursing</strong><br />
theories <strong>and</strong> nursing practice (pp. 433–444). Philadelphia: F. A. Davis.<br />
Turkel, M. (2006). Applicability of bureaucratic caring theory to contemporary nursing<br />
practice: The political <strong>and</strong> economic dimensions. In M. Parker (Ed.), <strong>Nursing</strong><br />
theories <strong>and</strong> nursing practice (2nd ed., pp. 369–379). Philadelphia: F. A. Davis.<br />
Turkel, M. (2007). Dr. Marilyn Ray’s theory of bureaucratic caring. International<br />
Journal for <strong>Human</strong> <strong>Caring</strong>, 11(4), 57–74.<br />
Turkel, M., & Ray, M. (2000). Relational complexity: A theory of the nurse-patient relationship<br />
within an economic context. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 13(4), 307–313.
PROLOGUE xxxvii<br />
Turkel, M., & Ray, M. (2001). Relational complexity: From grounded theory to instrument<br />
development <strong>and</strong> theoretical testing. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 14(4), 281–287.<br />
Turkel, M., & Ray, M. (2004). Creating a caring practice environment through selfrenewal.<br />
<strong>Nursing</strong> Administration Quarterly, 28(4), 249–254.<br />
Turkel, M., & Ray, M. (2009). <strong>Caring</strong> for “not-so-picture perfect patients”: Ethical<br />
caring in the moral community of nursing. In R. Locsin & M. Purnell (Eds.),<br />
A contemporary nursing process: The (un)bearable weight of knowing in nursing<br />
(pp. 225–249). New York: Springer.<br />
Turkel, M., Ray, M., & Kornblatt, L. (2011). Instead of reconceptualizing the nursing<br />
process, let’s rename it. <strong>Nursing</strong> <strong>Science</strong> Quarterly.<br />
Vicenzi, A., White, K., & Begun, J. (1997). Chaos in nursing: Make it work for you.<br />
American Journal of <strong>Nursing</strong>, 97(10), 26–31.<br />
Watson, J. (1979). <strong>Nursing</strong>: The philosophy <strong>and</strong> science of caring. Boulder, CO:<br />
University Press of Colorado.<br />
Watson, J. (1985). <strong>Nursing</strong>: <strong>Human</strong> science <strong>and</strong> human care. Norwalk, CT: Appleton-<br />
Century-Crofts.<br />
Watson, J. (2005). <strong>Caring</strong> science as sacred science. Philadelphia: F. A. Davis Company.<br />
Watson, J. (2008). <strong>Nursing</strong>: The philosophy <strong>and</strong> science of caring (2nd Rev. ed.).<br />
Boulder, CO: University Press of Colorado.<br />
Watson, J., & Smith, M. (2002). <strong>Caring</strong> science <strong>and</strong> the science of unitary human<br />
beings: A trans-theoretical discourse for nursing knowledge development. Journal<br />
of Advanced <strong>Nursing</strong>, 37(5), 452–461.<br />
Wheatley, M. (2006). Leadership <strong>and</strong> the new science (3rd ed.). San Francisco: Berrett-<br />
Koehler.<br />
White, J. (1995). Patterns of knowing: Review, critique, <strong>and</strong> update. Advances in<br />
<strong>Nursing</strong> <strong>Science</strong>, 17(4), 73–86.<br />
Wiggins, M. (2008). The challenge of change. In C. Lindberg, S. Nash, & C. Lindberg<br />
(Eds.), On the edge: <strong>Nursing</strong> in the age of complexity (pp. 1–21). Bordentown, NJ:<br />
Plexus Press.
Acknowledgments<br />
The completion of this book was a labor of love. The work first was conceived<br />
by Dr. Alice W. Davidson who, during the process of trying to achieve<br />
the goal of advancing scholarship to integrate nursing <strong>and</strong> complexity sciences<br />
for human–environment well-being, lost her life to cancer. As a coeditor<br />
with Alice, after her death, Dr. Marian Turkel stepped to, <strong>and</strong> together<br />
we have fulfilled Alice’s dream, the publication of this book. We learned that<br />
the foundation of complexity sciences is to illuminate patterns of wholeness,<br />
how all organisms are linked together coherently to reveal the artistic beauty<br />
<strong>and</strong> harmony of the universe. We know too that nursing is unitary <strong>and</strong> holistic,<br />
linked together in networks of relationship, principally the complex <strong>and</strong><br />
beautiful patterns of caring. We know by knowledge <strong>and</strong> experience that<br />
the ways of being <strong>and</strong> knowing as caring in nursing through the quality of<br />
the nurse–patient relationship facilitates healing, health, <strong>and</strong> well-being or<br />
a peaceful death. Through the scholarship expressed in this book by examining<br />
ideas advanced in the sciences of complexity, the science of unitary<br />
human beings, caring in nursing education, research, leadership, <strong>and</strong> practice,<br />
we recognize that the organic whole is not only diverse <strong>and</strong> unique<br />
but also, dynamic <strong>and</strong> self-organizing. The unique expressions are caritas<br />
processes, loving kindness, to use the words of Dr. Jean Watson. We are all<br />
unique expressions of the mutual human-environment caring relationship.<br />
The philosophies, theories, <strong>and</strong> scientific information expressed in this book<br />
help us to underst<strong>and</strong>, more than just in an intellectual way, how nursing,<br />
health care, <strong>and</strong> the social world are continuously unfolding in t<strong>and</strong>em, continuously<br />
emerging toward an authenticity of awareness of the meaning of<br />
holism, a developing awareness that everything is a living relationship.<br />
We would like to thank the following professionals who have made this<br />
work possible:<br />
n We are grateful to all the contributors to this book, our scientists, physicians,<br />
administrators <strong>and</strong> nursing colleagues from many universities, hospitals<br />
<strong>and</strong> military organizations who made this work a living treatise to<br />
underst<strong>and</strong>ing patterns of wholeness for health, healing <strong>and</strong> well-being.<br />
Our contributors are the finest scholars in their fields, <strong>and</strong> areas of scholarship<br />
<strong>and</strong> practice.<br />
xxxix
xl<br />
Acknowledgments<br />
n We are grateful to our colleague <strong>and</strong> friend, Dr. Jean Watson, Founder<br />
of the Watson <strong>Caring</strong> <strong>Science</strong> Institute, Boulder, Colorado, which is also<br />
connected with the Library at Springer Publishing Company.<br />
n We are grateful to M. Brooks Turkel, without whose diligence <strong>and</strong> attention<br />
to detail in computing <strong>and</strong> editing <strong>and</strong> his love <strong>and</strong> caring, the timeliness<br />
<strong>and</strong> accuracy of this work would not have been possible.<br />
n We are grateful to Drs. Madeleine Leininger <strong>and</strong> Jean Watson <strong>and</strong> Sister<br />
M. Simone Roach, who advanced the scholarship of caring <strong>and</strong> gave us a<br />
deep appreciation for <strong>and</strong> knowledge of human caring as the essence of<br />
nursing.<br />
n We are grateful to Drs. Anne Boykin <strong>and</strong> Savina Schoenhofer for the<br />
initial integration of caring into the nursing curriculum at Florida Atlantic<br />
University <strong>and</strong> to all our other professional colleagues at Florida Atlantic<br />
University who are dedicated to advancing caring science through education,<br />
practice, <strong>and</strong> research.<br />
n We are grateful to the faculty <strong>and</strong> Board of Directors of the Watson <strong>Caring</strong><br />
<strong>Science</strong> Institute; the professionals from the International Association for<br />
<strong>Human</strong> <strong>Caring</strong>, <strong>and</strong> the scholars from the Plexus Institute, the FAU Center<br />
for Complex Systems <strong>and</strong> Brain <strong>Science</strong>s, <strong>and</strong> the New Engl<strong>and</strong> Center for<br />
Complex Systems who gave us support <strong>and</strong> encouragement to fulfill the<br />
Alice’s dream.<br />
n We are grateful to Allan Graubard, Executive Editor, Springer Publishing<br />
Company, who trusted the process of the book’s unfolding as a “creative<br />
emergence” from the time when Dr. Davidson first approached him to<br />
the final submission of the work. We thank Assistant Editor, Elizabeth<br />
Stump, <strong>and</strong> the Production Editor, Rose Mary Piscitelli, for their work on<br />
our behalf.<br />
As Maturana <strong>and</strong> Varela remarked in their book The Tree of Knowledge (1992):<br />
We have only the world we can bring forth with others, <strong>and</strong> only love helps bring<br />
it forth . . . . (from Goodwin, B. [2003]. Patterns of wholeness: Holistic science.<br />
Resurgence, 1[216], p. 14)<br />
Marilyn A. (Dee) Ray<br />
Marian C. Turkel
ONE<br />
Philosophical <strong>and</strong> Theoretical<br />
Perspectives Related to <strong>Complexity</strong><br />
<strong>Science</strong> in <strong>Nursing</strong><br />
Marlaine Smith<br />
<strong>Nursing</strong> science has focused on complex systems in the study of<br />
nursing phenomena. The discipline of nursing is the study of<br />
relatiohip, human–environment patterning, <strong>and</strong> the complex dynamics<br />
related to caring <strong>and</strong> healing. Rogers’ science of unitary human<br />
beings (SUHB) has embedded within it many concepts consistent with<br />
complexity science. <strong>Complexity</strong> science is the transdisciplinary study<br />
of complex adaptive systems (CAS); it encompasses multiple theoretical<br />
perspectives <strong>and</strong> methods of inquiry <strong>and</strong> comprises a large number of<br />
entities displaying a high level of nonlinear (or noncausal) interactivity.<br />
Nurse scholars have recognized the importance of the unitary<br />
nature of the human <strong>and</strong> environment in caring for others, the difficulty<br />
of isolating parts of the unitary human–environment process,<br />
<strong>and</strong> the complexity or choices within continual emergence <strong>and</strong> change.<br />
In 1970, Rogers defined the unitary human–environment process as<br />
continuously changing, irreversible, <strong>and</strong> evolving toward increased<br />
innovation, diversity <strong>and</strong> higher frequency wave patterning. Building<br />
upon this foundation, the purpose ofthis chapter is to describe the interrelationships<br />
among select philosophic <strong>and</strong> theoretic perspectives in<br />
nursing <strong>and</strong> concepts in complexity science. Both Perkins <strong>and</strong> Reeder<br />
illuminate how there is a conceptual integration of complexity sciences,<br />
the SUHB, <strong>and</strong> caring in nursing. In this way they point out the uniqueness<br />
of nursing as a unitary caring science.<br />
Introduction<br />
The ideas embedded in complexity science are receiving increasing attention<br />
in many disciplines struggling to describe <strong>and</strong> explain phenomena in<br />
their fields of study. There is growing appreciation of the inadequacy of<br />
conventional models for underst<strong>and</strong>ing complex interrelated systems, <strong>and</strong><br />
this accounts for the emerging applications of complexity science in the<br />
physical, behavioral, biological, <strong>and</strong> human sciences. <strong>Nursing</strong> science has<br />
1
2 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
been one of the early adopters of ideas related to complexity science. With<br />
the discipline’s focus on the study of human health <strong>and</strong> healing through<br />
caring (Smith, 1994) or person–environment relationships that facilitate<br />
health (Fawcett, 2000), relationship emerges as central to the ontology<br />
<strong>and</strong> epistemology of nursing (Newman, Smith, Dexheimer-Pharris, &<br />
Jones, 2008); therefore, the study of relationships <strong>and</strong> approaches that<br />
account for interconnectedness <strong>and</strong> dynamism is essential. Multiple paradigms<br />
have emerged in nursing, with the unitary–transformative paradigm<br />
(Newman, Sime, & Corcoran-Perry, 1991) reflecting some of the distinguishing<br />
tenets of complexity science. This paradigm had its origins in<br />
the conceptual system for nursing developed by Martha Rogers (1970),<br />
the SUHB. Rogers introduced a worldview that posited humans <strong>and</strong> the<br />
environment as patterned energy fields without boundaries that were continuously<br />
changing <strong>and</strong> creatively emerging. The concepts within other<br />
nursing theories correspond with complexity thinking. The purpose of<br />
this chapter is to describe the interrelationships among selected philosophic<br />
<strong>and</strong> theoretic perspectives in nursing <strong>and</strong> concepts in complexity<br />
science. An overview <strong>and</strong> definition of the concepts in complexity science<br />
will be presented first, followed by an analysis of the fit with selected<br />
nursing theories. The chapter ends with some speculation about ways in<br />
which these ideas will continue to shape the direction of nursing inquiry,<br />
practice, <strong>and</strong> education for the future.<br />
Salient Concepts in <strong>Complexity</strong> <strong>Science</strong><br />
The literature is rife with multiple meanings of complexity science. In illuminating<br />
the “perplexity in complexity science,” Horgan (1995) reported that<br />
there were 31 definitions of complexity; most likely, there are many more<br />
in existence now. Fundamentally, complexity science is the transdisciplinary<br />
study of CAS; it encompasses multiple theoretical perspectives <strong>and</strong> methods<br />
of inquiry. Richardson, Cilliers, <strong>and</strong> Lissack (2000) provide a simple definition<br />
of a complex system as one “that is comprised of a large number of entities<br />
displaying a high level of non-linear interactivity” (p. 8). “<strong>Complexity</strong> science<br />
examines systems comprised of multiple <strong>and</strong> diverse interacting agents <strong>and</strong><br />
seeks to uncover the principles <strong>and</strong> dynamics that affect how such systems<br />
evolve <strong>and</strong> maintain order” (Lindberg & Lindberg, 2008, p. 32).<br />
Those espousing reductionistic perspectives of complexity science<br />
assert that the simple rules underlying complex patterns can be sorted<br />
out through mathematical models; others disagree. Some assert that the<br />
concepts of complexity science are not really being applied authentically<br />
in some disciplines but instead are used as metaphorical tools to explain<br />
observed phenomena (Haigh, 2002). <strong>For</strong> example, concepts such as the edge<br />
of chaos, emergence, <strong>and</strong> far from equilibrium may be used metaphorically
1: Philosophical <strong>and</strong> Theoretical Perspectives 3<br />
to describe an observed dynamic of a system. When applied in this way, the<br />
tenets of complexity are not ontological, or definitive of the nature of reality,<br />
but rather are adopted as an epistemological tool (metaphor) to underst<strong>and</strong><br />
an aspect of reality through comparison (Richardson & Cilliers, 2001). This<br />
might be considered as a pseudoscientific application of the thinking within<br />
complexity science <strong>and</strong> not the actual science itself. Some complexity scientists<br />
approach the study of complex systems through the methods of logical<br />
positivism, whereas others embrace methodological pluralism characteristic<br />
of a postmodern view. Phelan (2001) differentiates complexity science from<br />
complexity pseudoscience. <strong>Science</strong> involves the development <strong>and</strong> testing<br />
of theory through research. In contrast, pseudoscience uses resemblance<br />
thinking, neglects empirical matters, <strong>and</strong> is oblivious to alternative theories.<br />
Both complexity science <strong>and</strong> pseudoscience exist in nursing. Phelan argues<br />
that complexity theory <strong>and</strong> complexity thinking should be replaced with<br />
complexity science in some cases when the meaning reflects multiple ways<br />
of knowing, which, he argues, are not scientific. The dialogue related to<br />
complexity science is, in itself, complex. Choosing <strong>and</strong> defining one’s own<br />
perspective is necessary when clarifying one’s position among these multiple<br />
points of view.<br />
Perhaps the most encompassing notion of complexity science situates it<br />
as a worldview that underpins a particular philosophy of science. The purpose<br />
of any science is to create organizing frameworks to explain some aspect<br />
of reality <strong>and</strong> then to examine those frameworks for their empirical honesty<br />
(Smith, 1994). Dent (2000) asserts that “complexity science is an approach to<br />
research, study <strong>and</strong> perspective that . . . [embraces] the philosophical assumptions<br />
of the emerging worldview” (p. 5). A variety of authors (Bohm, 1980;<br />
Briggs & Peat, 1989; Capra, 1982; Ferguson, 1980; Harman, 1998; Prigogine &<br />
Stengers, 1984; Wilber, 1998) have described this emerging worldview <strong>and</strong><br />
argue that its appeal is related to the recognition that the traditional or<br />
empirical–analytic–mechanistic worldview underpinning science from a logical<br />
positivist perspective is inadequate. This traditional worldview provides<br />
some guidance for underst<strong>and</strong>ing phenomena within certain conditions, but<br />
beyond those conditions, its explanatory power is limited. Therefore, the<br />
emerging worldview encompasses the traditional within the limitations of<br />
its applicability while moving beyond it to explain the unexplainable within<br />
its perspective. This shift from the traditional to the emerging worldview is<br />
described as a time of dislocation (Ackoff, 1981), a period between “stories”<br />
(Schwartz & Ogilvy, 1979), a turning point (Capra, 1982), or new paradigm<br />
thinking (Ferguson, 1980).<br />
Table 1.1 is adapted from Dent (2000) <strong>and</strong> contrasts features of the<br />
traditional <strong>and</strong> emerging worldviews. The traditional or empirical–analytic–<br />
mechanistic worldview is consistent with Newtonian physics <strong>and</strong> its consequents<br />
of reductionism, discrete parts, local relationships, linear causality,<br />
objective reality, dualism, <strong>and</strong> a reliance on logic, prediction, averages,
4 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
Table 1.1 Comparison of the Traditional <strong>and</strong> Emerging Worldviews<br />
Traditional Worldview<br />
Emerging Worldview<br />
Reductionism<br />
Holism<br />
Focus on parts<br />
Focus on patterns<br />
Focus on discrete entities<br />
Focus on relationships<br />
Linear causality<br />
Mutual causality<br />
Local <strong>and</strong> linear relationships<br />
Nonlocal <strong>and</strong> nonlinear relationships<br />
Determinism<br />
Indeterminism, unpredictability<br />
Objective reality<br />
Perspectival reality; cocreated reality<br />
Observer outside the observation Observer influences the observation<br />
Systems adapt to stimuli<br />
Systems self-organize<br />
Logic<br />
Paradox<br />
Either/or thinking<br />
Polarity thinking<br />
Founded on Newtonian physics Founded on quantum physics<br />
Prediction<br />
Underst<strong>and</strong>ing/sensitivity; analysis/explanation<br />
Averages; homogeneity<br />
Diversity, variation<br />
Focus on outcomes<br />
Focus on emergence<br />
Matter creates mind<br />
Presence of consciousness in mind matter<br />
(Adapted from Dent, 2000)<br />
<strong>and</strong> homogeneity in the scientific method. In contrast, a quantum reality<br />
can acknowledge the Newtonian worldview in some circumstances, but its<br />
perspective also can embrace holism, patterns, relationships, nonlocal <strong>and</strong><br />
nonlinear processes, indeterminism, perspectival <strong>and</strong> cocreated reality,<br />
paradox, polarity, diversity, <strong>and</strong> emergence. Gleick (1987) predicted that<br />
the three scientific theories from the 20th century most relevant for the<br />
21st century would be the relativity, quantum, <strong>and</strong> chaos theories. The<br />
emerging worldview reflects these theories. Any theory is a map of the territory<br />
(reality); the real territory is always more complex than any map can depict.<br />
Each theory explains a range of phenomena; however, it may be totally inadequate<br />
for others. The emerging theories of complexity science address some<br />
of the unexplained gaps inherent in the traditional worldview (Capra, 1982;<br />
Coppa, 1993).<br />
The structure of traditional <strong>and</strong> emergent worldviews corresponds to<br />
the worldviews underpinning paradigms within nursing science. These<br />
ontological paradigms contrast the different views of the nature of human<br />
beings, human–environment relationships, <strong>and</strong> health that shape approaches<br />
to nursing epistemology, methodology, <strong>and</strong> practice. Parse (1987) describes
1: Philosophical <strong>and</strong> Theoretical Perspectives 5<br />
two paradigms in nursing: the simultaneity <strong>and</strong> the totality. Those with the<br />
lens of the totality paradigm perceive persons as composed of interrelated<br />
<strong>and</strong> interacting dimensions or parts; person <strong>and</strong> environment are separate<br />
but interactive, <strong>and</strong> health is biopsychosocial well-being, often depicted<br />
on a continuum from wellness to illness (or death). Parse (1987) asserted<br />
that Rogers’ <strong>Science</strong> of Unitary Man (sic), now the <strong>Science</strong> of Unitary<br />
<strong>Human</strong> Beings (SUHB) published in 1970, ushered in the simultaneity<br />
paradigm. In this paradigm person-environment is viewed as an irreducible<br />
whole <strong>and</strong> health as a pattern of the whole. In 1991 Newman, Sime, &<br />
Corcoran-Perry named three paradigms in nursing as the particularistic–<br />
deterministic, the interactive–integrative, <strong>and</strong> the unitary–transformative.<br />
The deterministic perspective corresponds closely with the traditional<br />
worldview; the interactive–integrative worldview offers a systems perspective<br />
that acknowledges human adaptation to the environment <strong>and</strong><br />
the expression of this adaptation in subsystems. The unitary–transformative<br />
paradigm in nursing corresponds to the emerging worldview. Coming<br />
from this perspective, science is conducted differently. There is an attempt<br />
to underst<strong>and</strong> “the evolving pattern of the whole” (Newman, 2008, p. 14).<br />
<strong>Nursing</strong> theories are clustered under these worldviews. The simultaneity <strong>and</strong><br />
unitary–transformative paradigms have close similarities with the emerging<br />
worldview <strong>and</strong> complexity theory. This paradigm asserts the existence of<br />
human–environment patterning that reflects a fundamental wholeness, a<br />
dynamic process of change, <strong>and</strong> creative emergence based on participation<br />
<strong>and</strong> growing complexity.<br />
As stated earlier, complexity science is known also as a theory of complex<br />
adaptive systems (CAS). In Table 1.2, the defining elements of CAS<br />
are identified. CAS are characterized by qualities such as embeddedness,<br />
nonlinearity, unpredictability, self-organization, diversity, porous boundaries,<br />
<strong>and</strong> emergent behavior (Chaffee & McNeill, 2007; Lindberg & Lindberg,<br />
2008). Chaos theory is a subset of complexity science; its central tenet is that<br />
order underlies <strong>and</strong> emerges from apparent disorder. Although turbulent<br />
systems seem to exhibit chaotic behavior, order emerges from a communication<br />
point or phase space (Ray, 1998).<br />
CAS are composed of interdependent <strong>and</strong> adaptive elements. There is a<br />
fundamental assertion that there is a simple rule that when discovered will<br />
show the unity of the life sciences (Lewin, 1992). The internal structures of<br />
complex systems are not reducible to a mechanical system (Allen, 2001, p. 30).<br />
These systems coevolve with their environment, open to flows of energy,<br />
matter, <strong>and</strong> information (p. 39). The evolution is creative <strong>and</strong> uncertain.<br />
There is a changing system embedded in a l<strong>and</strong>scape of potential attractors<br />
that influence change. This is “transformational teleology” (Stacey, Griffen, &<br />
Shaw, 2000) as the potential futures (patterns of attractors) are transformed<br />
in the present (Allen, 2001, p. 40).
6 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
Table 1.2 Correspondence of Concepts Related to CAS to Extant <strong>Nursing</strong> Theories<br />
Concept<br />
Embeddedness<br />
Dynamism<br />
Patterning<br />
Coevolution<br />
Definition<br />
CAS exist within<br />
larger systems that<br />
provide context for<br />
underst<strong>and</strong>ing each.<br />
CAS are in continuous<br />
change; stability is not<br />
expected or desired.<br />
CAS have unique<br />
configurations of<br />
movement <strong>and</strong> flow<br />
that identify each.<br />
CAS simultaneously<br />
shape <strong>and</strong> are shaped<br />
by their interactions<br />
with other systems.<br />
Correspondence<br />
to <strong>Nursing</strong> Theories<br />
Rogers’ postulate of open systems<br />
<strong>and</strong> principle of integrality: <strong>Human</strong>s<br />
<strong>and</strong> environment are energy fields,<br />
coextensive with the universe <strong>and</strong> in<br />
continuous, mutual process.<br />
Newman describes individual patterns<br />
of consciousness embedded in<br />
family <strong>and</strong> community patterns. Roy’s<br />
philosophical assumptions related to<br />
cosmic unity.<br />
Rogers’ postulates <strong>and</strong> principles<br />
of helicy <strong>and</strong> resonancy: Change<br />
in human–environmental energy<br />
field is continuous, innovative, <strong>and</strong><br />
unpredictable with greater diversity of<br />
field patterning.<br />
Roy describes persons as holistic<br />
adaptive systems with coping processes<br />
that maintain adaptation <strong>and</strong> promote<br />
person <strong>and</strong> environment transformations.<br />
Rogers’ postulates of energy field,<br />
open systems, <strong>and</strong> pattern <strong>and</strong><br />
organization: Each energy field has a<br />
distinguishing pattern, a single wave<br />
that differentiates it from others.<br />
Newman’s concept of pattern of<br />
the whole with movement, time,<br />
<strong>and</strong> space as patterns of evolving<br />
consciousness.<br />
Davidson stated that patterning could<br />
shift from stability to radical changes<br />
<strong>and</strong> that patterning over time should<br />
be studied through a perceptual dance<br />
between the parts <strong>and</strong> the whole.<br />
Rogers’ postulates of open systems:<br />
<strong>Human</strong> <strong>and</strong> environment energy fields<br />
are in continuous mutual process.<br />
Newman asserts that nurse <strong>and</strong><br />
client evolve together in the mutual<br />
relationship.<br />
Parse’s principle that humans are cotranscending<br />
with the possibles.
1: Philosophical <strong>and</strong> Theoretical Perspectives 7<br />
Table 1.2 (Continued)<br />
Concept<br />
Emergence<br />
Inherent integrity<br />
Nonlinearity<br />
Porous boundaries<br />
Definition<br />
Creative <strong>and</strong> innovative<br />
change occurs at the<br />
edge of the system<br />
where there is the<br />
most disorganization<br />
<strong>and</strong> disorder.<br />
CAS possess unity<br />
<strong>and</strong> structure.<br />
The direction of<br />
dynamic change in<br />
CAS is unpredictable.<br />
A small action by an<br />
agent may produce<br />
a large change in the<br />
CAS <strong>and</strong> vice versa.<br />
CAS have open<br />
boundaries that<br />
permit continuous<br />
interaction with other<br />
systems.<br />
Correspondence<br />
to <strong>Nursing</strong> Theories<br />
Rogers’ principles of helicy. Change<br />
in human–environmental field<br />
patterning is continuous, innovative,<br />
<strong>and</strong> unpredictable. <strong>Human</strong>s <strong>and</strong><br />
environment are evolving toward<br />
increasing complexity <strong>and</strong> diversity of<br />
field patterning. Rogers’ assumption<br />
of negentropy, that the life process is<br />
evolving toward greater complexity<br />
<strong>and</strong> order, was not consistent with the<br />
concept of order emerging from chaos.<br />
Newman’s ideas that disruption<br />
<strong>and</strong> disorder (disease) can lead<br />
to a choice point <strong>and</strong> exp<strong>and</strong>ing<br />
consciousness (health).<br />
Parse’s principle that humanbecoming<br />
as negentropic unfolding.<br />
Turkel <strong>and</strong> Ray describe the emergence of<br />
relational complexity as a creative change<br />
in the system when economics <strong>and</strong><br />
caring are viewed in a dialectic whole.<br />
Reed asserts that growing selftranscendence<br />
occurs with aging <strong>and</strong><br />
crisis.<br />
Rogers’ postulate of pattern: Pattern<br />
provides integrity to the energy field; it<br />
identifies it <strong>and</strong> distinguishes it.<br />
Roy’s person as adaptive system<br />
emphasizes the importance of system<br />
integrity through stability <strong>and</strong> change.<br />
Adaptive responses promote integrity.<br />
Rogers’ postulate of open systems<br />
<strong>and</strong> principle of helicy: <strong>Human</strong>–<br />
environmental energy fields are in<br />
continuous mutual process. Change<br />
in human–environmental energy field<br />
patterning is continuous, innovative,<br />
<strong>and</strong> unpredictable. Attunement <strong>and</strong><br />
resonance are nonlinear processes of<br />
acquiring knowledge.<br />
Rogers’ postulate of energy fields <strong>and</strong><br />
open systems: Energy fields, by their<br />
nature, have no boundaries; they are<br />
in continuous, mutual process.<br />
(continued)
8 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
Table 1.2 (Continued)<br />
Concept<br />
Self-organization<br />
Simple rules<br />
Diversity<br />
Definition<br />
CAS have the ability<br />
to influence their<br />
structure <strong>and</strong> direction<br />
by creating new<br />
patterns through<br />
interactions with other<br />
systems.<br />
Underlying CAS are<br />
rules that govern the<br />
behavior of interacting<br />
agents over time<br />
using feedback<br />
<strong>and</strong> algorithms.<br />
These rules, when<br />
discovered, will lead<br />
to a unity of the life<br />
sciences. The CAS<br />
evolves creative<br />
possibilities through<br />
learning as a whole.<br />
Agents or elements in<br />
the CAS are varied<br />
<strong>and</strong> unique, <strong>and</strong> these<br />
differences are critical<br />
for system health.<br />
Correspondence<br />
to <strong>Nursing</strong> Theories<br />
Rogers’ principle of helicy <strong>and</strong><br />
Barrett’s theory of power as knowing<br />
participation in change: Change is<br />
continuous, dynamic, <strong>and</strong> creative,<br />
<strong>and</strong> humans participate knowingly<br />
in the process of change; humans<br />
participate knowingly in change<br />
through awareness, choice, freedom<br />
to act intentionally, <strong>and</strong> involvement in<br />
creating change.<br />
Newman’s ideas of transformation<br />
through pattern recognition; shifts<br />
occur as client recognizes own<br />
patterning.<br />
Davidson found that in complex<br />
human–environment interrelationships<br />
choice is important for well-being.<br />
Turkel <strong>and</strong> Ray describe the selforganizing<br />
characteristics of the work<br />
environment occurring as forces of<br />
economic accountability <strong>and</strong> need for<br />
relationship converge.<br />
Roy’s scientific assumption: Systems<br />
progress to a higher level of<br />
complexity <strong>and</strong> self-organization.<br />
Turkel <strong>and</strong> Ray describe a search<br />
for unity in relational complexity, a<br />
dialectic synthesis that resolves the<br />
tension between economics <strong>and</strong><br />
caring.<br />
Ray defines caring as the energy by<br />
which choice is facilitated to bring<br />
order (healing or well-being) out of<br />
chaos (disease, need, pain, or crisis).<br />
Rogers described increasing diversity<br />
as a manifestation of patterning.
1: Philosophical <strong>and</strong> Theoretical Perspectives 9<br />
Table 1.2 (Continued)<br />
Concept<br />
Polarity<br />
<strong>and</strong> paradox:<br />
order–disorder<br />
Adaptable elements<br />
Distributed control<br />
Attractors<br />
Definition<br />
CAS are characterized<br />
by a wholeness that<br />
embraces dialectic<br />
rhythms. The<br />
fluctuations of these<br />
opposing forces<br />
are preferred over<br />
stability.<br />
CAS are composed<br />
of elements that<br />
can evolve with<br />
environmental<br />
changes.<br />
CAS do not direct<br />
change centrally; the<br />
agents participate<br />
in direction of<br />
change <strong>and</strong> resultant<br />
outcomes.<br />
System catalysts<br />
that promote the<br />
emergence of new<br />
behaviors.<br />
Correspondence<br />
to <strong>Nursing</strong> Theories<br />
Rogers’ principle of resonancy<br />
asserts that human patterning<br />
evolves toward more diverse<br />
manifestations evident in opposing<br />
rhythms that evolve toward a unity<br />
(dialectic synthesis); for example,<br />
the pattern of sleeping, waking, <strong>and</strong><br />
beyond waking.<br />
Newman asserts that the concept of<br />
health encompasses both disease<br />
<strong>and</strong> nondisease.<br />
Davidson states that chaotic patterns<br />
give rise to ordered patterns in<br />
human life.<br />
In Parse’s humanbecoming school of<br />
thought, the paradoxical rhythms of<br />
revealing–concealing, connecting–<br />
separating, <strong>and</strong> enabling–limiting<br />
describe the patterns of relating. The<br />
paradoxical rhythms reflect the whole.<br />
In their theory, Turkel <strong>and</strong> Ray focus<br />
on the paradox of economics <strong>and</strong><br />
caring <strong>and</strong> its resolution in relational<br />
complexity.<br />
Roy’s theory of adaptive system states<br />
that there are internal processes that<br />
act to maintain the integrity of the<br />
individual or group.<br />
Rogers’ principle of helicy states that<br />
the nature <strong>and</strong> direction of change are<br />
a function of knowing participation in<br />
the human–environment process.<br />
Ray identifies caring as an attractor<br />
that moves the system toward order<br />
in chaos.<br />
This table was constructed from a synthesis of Lindberg, C. (2008). Nurses take note: A primer<br />
on complexity science. In C. Lindberg, S. Nash, & C. Lindberg (Eds.), On the edge: <strong>Nursing</strong> in<br />
the age of complexity. Bordentown, NJ: Plexus Press.<br />
Chaffee, M., & McNeil, M. (2007). A model of nursing as a complex adaptive system. <strong>Nursing</strong><br />
Outlook, 55(5), 232–241e. DOI: 10.1016/J. outlook; 2007.04.003
10 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
Relationship of <strong>Complexity</strong> Thinking to <strong>Nursing</strong> Theories<br />
In 1970, Martha Rogers published her groundbreaking book, An Introduction<br />
to the Theoretical Basis of <strong>Nursing</strong>. In this book, Rogers provided the foundations<br />
for her conceptual system, now called the science of unitary human<br />
beings (SUHB), offering a radical alternative to existing conceptualizations<br />
about the relationships between human beings, their environment, <strong>and</strong> the<br />
nature of the life process.<br />
Rogers recognized the limitations of the existing models within science<br />
<strong>and</strong> medicine that reduced, categorized, <strong>and</strong> classified human phenomena <strong>and</strong><br />
sought to predict human–environment relationships through hypothesizing<br />
the direction of reactions to environmental stimuli. This model led to prescriptions<br />
to change human behavior toward desired outcomes. Rogers proposed<br />
a nursing lens focused on the wholeness, interconnectedness, <strong>and</strong> complexity<br />
of the life process as the foundation for nursing science, with a goal of “better<br />
health for mankind [sic]” (p. xii). She drew from tenets of general systems<br />
theory, evolutionary biology <strong>and</strong> cosmology, relativity theory, <strong>and</strong> quantum<br />
mechanics in the creation of a wholly new conceptual system that, in many<br />
ways, preceded or paralleled the emerging foundations of complexity science.<br />
She argued against the application of systems theories to underst<strong>and</strong> human<br />
life. Instead, she called for the life process to be understood in its wholeness<br />
as reflected in pattern <strong>and</strong> organization.<br />
Rogers asserted that the life process is inherently complex <strong>and</strong> dynamic.<br />
“An energy field underwrites the unity of man [sic] <strong>and</strong> provides the conceptual<br />
boundaries which identify his [sic] oneness. A field transcends its<br />
component parts . . . <strong>and</strong> possesses its own integrity. <strong>Human</strong> beings are<br />
more than <strong>and</strong> different from the sum of their parts” (p. 46). The notion of<br />
both humans <strong>and</strong> environments as energy fields sets the stage for a boundaryless<br />
integral relationship between the two. <strong>Human</strong> beings coevolve with<br />
their environment. This perspective contradicts the notions of orderly or<br />
predictable adaptation to environmental stimuli. Likewise, without boundaries<br />
between humans <strong>and</strong> the environment, there can be no predictable<br />
outcomes, only dynamic change cocreated through participation.<br />
Rogers (1990, 1994) viewed living systems as continually becoming,<br />
that is, growing, more diverse <strong>and</strong> complex. This contradicted the second<br />
law of thermodynamics, entropy, setting the stage for its opposite, the<br />
concept of negentropy, the continuous, dynamic change toward greater<br />
complexity that characterizes human life. Emergence <strong>and</strong> unpredictability<br />
are natural consequences of this assumption. “The capacity of life to<br />
transcend itself, for new forms to emerge, for new levels of complexity to<br />
evolve, predicates a future that cannot be foretold” (Rogers, 1970, p. 57).<br />
Rogers’ postulate of pattern <strong>and</strong> organization is founded on the<br />
premise that complex whole systems are known by their patterns. The<br />
energy field imposes pattern; pattern reflects the wholeness of human
1: Philosophical <strong>and</strong> Theoretical Perspectives 11<br />
life (Rogers, 1970, p. 61). Pattern is dynamic <strong>and</strong> observable through its<br />
manifestations. Self-regulatory or self-organizing characteristics of pattern,<br />
included in her 1970 book, were later rejected because of their violation of<br />
the coevolving, integral nature of the person–environment mutual process.<br />
<strong>Human</strong> beings participate knowingly in change (1990, 1994) through making<br />
choices, but they do not regulate or organize themselves in isolation.<br />
Rogers also argued that chaos theory was not consistent with a unitary<br />
perspective. She considered the premise of chaos theory, that if the conditions<br />
<strong>and</strong> context of any event are known the outcomes can be predicted,<br />
inconsistent with an open systems perspective. Furthermore, she found<br />
the idea that order emerges at the edge of chaos as contrary to a worldview<br />
where emergence is continually unpredictable, creative, <strong>and</strong> diverse.<br />
Theories have been derived from Rogers’ conceptual system. One is the<br />
theory of accelerating evolution (Rogers, 1970, 1990), that more complex life<br />
forms evolve more rapidly <strong>and</strong> that change is accelerating. She suggested that<br />
we would witness more complex <strong>and</strong> diverse patterning manifestations such<br />
as hyperactivity, extrasensory perception, <strong>and</strong> changes in sleep–wake patterns<br />
over time. Perhaps the precipitous change in communication through technology<br />
is another example of this theory of accelerating evolution. Barrett’s<br />
(1986) theory of power as participating knowingly in change is another<br />
theory derived from the SUHB. Barrett asserts that humans have the power<br />
to participate in change through awareness, choice, freedom to act intentionally,<br />
<strong>and</strong> involvement in creating change. Her theory provides a blueprint for<br />
promoting participation in change within complex situations.<br />
Rosemarie Parse’s (1998) The <strong>Human</strong>becoming School of Thought <strong>and</strong><br />
Margaret Newman’s (1986, 1994) Theory of Health as Exp<strong>and</strong>ing Consciousness<br />
(HEC) were developed, in part, from Rogers’ SUHB; therefore, both of these<br />
theories fall within the simultaneity or unitary–transformative paradigms <strong>and</strong><br />
resonate with the complexity theory concepts. The theory of humanbecoming<br />
(Parse, 1998) (formerly man-living health [Parse, 1981]), by its name, suggests<br />
that a process of emergence characterizes health. Parse asserts that human<br />
beings cocreate patterns of relating with their environments. These patterns<br />
manifest in the paradoxical rhythms of revealing– concealing, connecting–<br />
separating, <strong>and</strong> enabling–limiting. From Parse’s perspective, these rhythms<br />
constitute the pattern of a whole. <strong>Human</strong>becoming is co-transcending with<br />
the possibles. These themes, embodied in the theory’s principles, are consistent<br />
with complexity thinking related to interconnectedness, paradox,<br />
<strong>and</strong> emergence.<br />
Margaret Newman’s theory of Health as Exp<strong>and</strong>ing Consciousness (HEC)<br />
(1986, 1994) draws from Rogers’ (1970) SUHB, Young’s (1976) theory of the<br />
evolution of consciousness, Bohm’s (1980) theory of the holographic universe,<br />
<strong>and</strong> Prigogine’s (1984) theory of dissipative structures, all of which<br />
have correspondence with selected ideas in complexity science. “The focus<br />
is on the person, the pattern of the evolving whole, of transformations within
12 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
transformations, including the unpredictability of chaotic systems” (Newman,<br />
2008, p. 8). According to Newman, health is a higher unity encompassing<br />
both having disease <strong>and</strong> being free from it. Having a disease may be an<br />
impetus for movement to a choice point <strong>and</strong> a higher level of organization.<br />
This relates to Prigogine’s (1984) theory in which a period of disorganization<br />
can be the impetus for movement to a higher level of organization. Persons<br />
experiencing the disruptive patterning associated with disease may arrive at<br />
a choice point where they develop awareness, recognize their pattern, make<br />
decisions, <strong>and</strong> take actions that become life transforming. This is exp<strong>and</strong>ing<br />
consciousness. According to HEC, knowing through attunement <strong>and</strong> resonance<br />
is a more complex way of knowing the whole that may result in intuitive<br />
insights <strong>and</strong> revelation (Newman, 2008, p. 37). This process of seeing<br />
the whole in parts is a key to pattern recognition. These ideas are consistent<br />
with the concepts of creative emergence, hidden unity, <strong>and</strong> self-organization<br />
related to complexity theory.<br />
Sr. Callista Roy’s (2008) conceptual model of person as adaptive system<br />
has evolved over time, incorporating some qualities related to complexity<br />
science <strong>and</strong> complex adaptive systems. Her model evolved from general system<br />
theory <strong>and</strong> adaptation theory, <strong>and</strong> later, she incorporated from Young<br />
(1976) the ideas of unity <strong>and</strong> meaningfulness in the created universe. Her<br />
recent work (Roy, 2009; Roy & Jones, 2007) places greater emphasis on<br />
the complexity of the times in which we live <strong>and</strong> how this compels the<br />
need for greater unity <strong>and</strong> spiritual vision. Roy’s philosophical assumption<br />
related to cosmic unity reflects the interconnectedness of persons to a larger<br />
whole. In her scientific assumptions, Roy (2010) states that systems of matter<br />
<strong>and</strong> energy progress to higher levels of complex self-organization; that<br />
consciousness <strong>and</strong> meaning are consistent with person <strong>and</strong> environment<br />
integration; that choice results in the integration of creative processes; that<br />
there are integral relationships between persons <strong>and</strong> the earth; <strong>and</strong> that person<br />
<strong>and</strong> environment transformations have created human consciousness<br />
(p. 170). These scientific assumptions clearly reflect a movement toward a<br />
unitary–transformative worldview consistent with the fundamental premises<br />
of complexity science.<br />
Pamela Reed’s (1991) middle range self-transcendence theory was built<br />
on assumptions from Rogers’ SUHB. Reed defines living systems as open,<br />
self-organizing, <strong>and</strong> developing through periods of disequilibrium. She<br />
asserts that in the life process humans develop in the direction of greater<br />
complexity. One of the indicators of this is growing self-transcendence, <strong>and</strong><br />
this quality is often seen in the aging process. However, self-transcendence can<br />
be accelerated during times of vulnerability or crisis, when persons experience<br />
deeper connections to self <strong>and</strong> others <strong>and</strong> an increasing focus on contributing<br />
to a greater good.<br />
Alice Davidson, under the guidance of her doctoral mentor, Marilyn Ray<br />
(Davidson & Ray, 1991), was one of the first nursing scholars to draw explicitly
1: Philosophical <strong>and</strong> Theoretical Perspectives 13<br />
from the tenets of complexity science in her research related to human–<br />
environment interrelationships. She built on Rogers’ (1970, 1990) principle<br />
of integrality <strong>and</strong> asserted that patterns may appear stable or can shift dramatically<br />
from previous patterning. Davidson hypothesized that apparent<br />
chaotic patterns may give rise to greater order in human life <strong>and</strong> that humans<br />
come to know the environment through a perceptual dance of focusing on<br />
parts <strong>and</strong> the whole. This dialectical movement is essential to underst<strong>and</strong>ing<br />
the complex, relational, human–environment process. In order to underst<strong>and</strong><br />
this, Davidson designed a study using multiple methods to examine complex<br />
relationships. Her process of studying the human–environment relationship<br />
evolved from complexity theory <strong>and</strong> included the following: (1) apprehension<br />
of the whole to determine data needed; (2) examination of the manifestations<br />
of the whole collected as data; (3) analysis of data according to the<br />
appropriate traditional paradigm; (4) dialectical movement among the findings;<br />
(5) pattern identification across paradigms; (6) application of boundaries<br />
of existing underst<strong>and</strong>ings from data, literature review, <strong>and</strong> so on;<br />
(7) boundary crossing by reversing <strong>and</strong> questioning; (8) disengagement <strong>and</strong><br />
enabling ideas to be transformed into new patterns or creative insights of<br />
meaning making; (9) intuiting an underst<strong>and</strong>ing of the phenomenon (unity<br />
of meaning), <strong>and</strong>; (10) communicating meaning to others through language<br />
<strong>and</strong> practice (p. 77).<br />
Davidson’s research question was: How does the integral human–<br />
environment relationship facilitate human beings’ well-being as manifest in<br />
production <strong>and</strong> creativity? Participants were workers within an organization.<br />
Data generation included the following: participant observation <strong>and</strong> action<br />
research; causal modeling; phenomenology <strong>and</strong> hermeneutic analysis of the<br />
totality of the data. Based on her research, she developed a theory of choice<br />
patterns, asserting the importance of choice for human beings as they promote<br />
their own unique well-being. Later Davidson <strong>and</strong> colleagues (Davidson,<br />
Teicher, & Bar-Yam, 1997) tested this theory <strong>and</strong> found that for the elderly<br />
to remain active <strong>and</strong> productive they needed sufficient complexity in their<br />
human–environment relationships to stimulate <strong>and</strong> challenge them.<br />
Several nurse scholars have written about the relationship of chaos<br />
theory to nursing theories (Mishel, 1990; Vicenzi, 1994; Ray, 1994). Gleick<br />
(1987) defines chaos as the apparent irregular, unpredictable behavior of<br />
deterministic, nonlinear dynamic systems. It is referred to as “deterministic<br />
r<strong>and</strong>omness” (Vicenzi, 1994, p. 37). Mishel (1990) used chaos theory as a way<br />
to reconceptualize her middle range theory of uncertainty in illness to reflect<br />
the changes that occur in people when uncertainty is prolonged. Disorder,<br />
instability, diversity, <strong>and</strong> disequilibrium characterize systems in chaos; these<br />
characteristics correspond to the experiences of persons confronting the<br />
continuing <strong>and</strong> prolonged crises associated with the uncertainty during a<br />
chronic illness. Mishel draws the comparison of prolonged uncertainty with<br />
far-from-equilibrium dynamics in which very small external changes can
14 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
affect profound internal changes within the system <strong>and</strong> the system can<br />
dramatically self-organize. Continuing this analogy Mishel theorizes that<br />
entropy, or the degree of disorder <strong>and</strong> disorganization in life, increases<br />
in persons who are in the midst of unabating uncertainty. Persons cannot<br />
withst<strong>and</strong> this mounting uncertainty <strong>and</strong> are pushed to a bifurcation point<br />
when there is either death or a change toward a more complex level of<br />
self-organization.<br />
Vicenzi (1994) suggested that chaos theory could provide a new synthesis<br />
for nursing <strong>and</strong> community health; she was one of the first to<br />
relate the concepts of chaos theory to nursing theory <strong>and</strong> health-related<br />
phenomena. <strong>For</strong> example, she suggests that perhaps nursing intuition is<br />
a prereflective sensing of chaos <strong>and</strong> that heart rate variability, neutrophil<br />
counts, epilepsy, <strong>and</strong> schizophrenia exhibit chaotic dynamics. Sensitive<br />
dependence is a concept in chaos theory sometimes called the “butterfly<br />
effect,” referring to the phenomenon that small change can lead to<br />
extreme effects in the long term (p. 38). She relates these concepts to<br />
Rogers’ (1990) postulates of unpredictability <strong>and</strong> irreducibility, <strong>and</strong> suggests<br />
that nurse scientists might increase their use of longitudinal research<br />
designs <strong>and</strong> computer modeling to come to underst<strong>and</strong> the wholeness<br />
<strong>and</strong> complexity of human patterning.<br />
Ray (1994) situates her theory of complex caring dynamics within the<br />
context of complexity science <strong>and</strong> chaos theory. The foundations of her<br />
theory are in a relational ontology patterned by love. She states that “selforganization<br />
in chaos theory, although seemingly without a goal, is influenced<br />
by creativity—a vision of a purposeful love, a purposeful God, a force<br />
or spirit of life expressing itself intelligently in the universe” (Ray, 1994,<br />
p. 25). Ray argues effectively that the concepts of relationality, belongingness,<br />
holism, self-organization, human–environment integrality, patterning,<br />
stages of organization–disorganization stages, unidirectionality of change, <strong>and</strong><br />
pattern recognition are contained within nursing <strong>and</strong> consistent with complexity<br />
theory (Ray, 1994, p. 25). <strong>Caring</strong> is defined as “the energy by which choice<br />
is facilitated to bring order (healing or well-being) out of chaos (disease, disease,<br />
need, pain, or crisis)” (Ray, 1994, p. 26). Ray describes the caring<br />
relationship as an attractor that draws the system away from chaos <strong>and</strong> toward<br />
well-being <strong>and</strong> healing. In this relationship, the nurse instills hope, leading to<br />
choice making that changes the pattern so that both nurse <strong>and</strong> client are “more<br />
alive <strong>and</strong> authentic” than before (Ray, 1994, p. 26). She identifies four life pattern<br />
forms related to pattern seeing: technical, practical, critical, <strong>and</strong> creative<br />
caring dynamics. Each has its corresponding methodological frameworks for<br />
pattern mapping <strong>and</strong> integrative synthesis or pattern recognizing. The theory<br />
of complex caring dynamics highlights the primacy of relationships or love as<br />
the pull of the universe toward creative emergence or healing.<br />
Turkel <strong>and</strong> Ray (2000, 2001) developed a theory of relational complexity<br />
that describes <strong>and</strong> explains the importance of caring in the complexity of
1: Philosophical <strong>and</strong> Theoretical Perspectives 15<br />
the current health care environment. The theory’s assumptions flow from<br />
a unitary–transformative worldview embracing complexity, exp<strong>and</strong>ing consciousness<br />
<strong>and</strong> transformation, <strong>and</strong> ideas of paradoxical patterning <strong>and</strong><br />
living changing value priorities within Parse’s theory of human becoming<br />
(Turkel & Ray, 2001). They assert that the current health care environment<br />
is driven by the economic factors of regulation, reimbursement, <strong>and</strong> costs.<br />
This environment can influence nursing practice so that it becomes shaped<br />
by the dem<strong>and</strong>s of increasing patient acuity <strong>and</strong> time constraints imposed<br />
by increasing documentation <strong>and</strong> decreased staffing. This can lead to compromised<br />
quality <strong>and</strong> safety outcomes for patients, including well-being <strong>and</strong><br />
quality of life. On the other h<strong>and</strong>, nursing places caring <strong>and</strong> relationship<br />
prominently within its discipline <strong>and</strong> profession. The seeming paradoxical<br />
forces of economics <strong>and</strong> caring must be reconciled through a codetermining<br />
relationship (interidentification), a transformation of quantity into quality<br />
(qualitative difference), the negation of negation (dialectic resolution), <strong>and</strong><br />
a spiral form of development (transformation <strong>and</strong> change) (Turkel & Ray,<br />
2001, p. 282).<br />
Turkel <strong>and</strong> Ray (2000) propose that a shift in the self-organizing pattern<br />
of interrelationships among the nurse, administrator, <strong>and</strong> patient can<br />
change this dynamic. This shift occurs when caring <strong>and</strong> relationship become<br />
the organizing force for patterning. When this occurs, the nurse–patient–<br />
administrator relationship becomes an economic resource for the organization.<br />
They propose a synthesis of caring <strong>and</strong> economics that will result<br />
in fulfillment of the organization’s mission, economic enhancement, actualization<br />
of the nurse–patient relationship to its full potential, <strong>and</strong> patient<br />
outcomes of enhanced healing <strong>and</strong> well-being. In Turkel <strong>and</strong> Ray’s theory,<br />
human caring <strong>and</strong> economics are synthesized into relational complexity in<br />
an economic context in which the result is “ethical economic caring” (Ray,<br />
1994, p. 50). This reflects the tenets of complexity science related to the<br />
edge of chaos, where the emergence of order from disorder can be found<br />
in a choice point <strong>and</strong> hidden unity becomes revealed.<br />
<strong>Complexity</strong> Thinking <strong>and</strong> the Future of <strong>Nursing</strong> Inquiry,<br />
Practice, <strong>and</strong> Education<br />
<strong>Complexity</strong> thinking is taking root <strong>and</strong> growing across disciplines; it can<br />
only continue to spread within the discipline of nursing, affecting nursing<br />
inquiry, practice, <strong>and</strong> education. In the past 30 years, nursing has<br />
recognized the importance of multiple epistemologies <strong>and</strong> philosophies of<br />
science. <strong>Complexity</strong> science is founded in an emerging worldview that contrasts<br />
with the traditional worldview that guides scientific inquiry. This<br />
emerging worldview (Table 1.1) will continue to guide inquiry within<br />
the discipline allowing for, perhaps even compelling, the use of multiple
16 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
methods of inquiry in underst<strong>and</strong>ing the whole of complex phenomena.<br />
Several authors (Koithan, 2006; Resnicow & Page, 2008) point to the<br />
advantage of chaos <strong>and</strong> complexity in offering a valuable explanatory<br />
model for public health research <strong>and</strong> behavior change, <strong>and</strong> the study<br />
of whole systems approaches to healing. The limitations of r<strong>and</strong>omized<br />
clinical trials in underst<strong>and</strong>ing the depths of the human experience, the<br />
interrelationship of power <strong>and</strong> knowledge, <strong>and</strong> the participatory nature<br />
of knowledge generation are evident. However, r<strong>and</strong>omized clinical trials<br />
<strong>and</strong> other methods of empirical inquiry have their place in answering<br />
important questions related to phenomena of concern to nursing. In the<br />
future, nursing will transcend the boundaries of qualitative/quantitative<br />
<strong>and</strong> traditional science/human science dichotomies to embrace methods<br />
that require multiple perspectives on a single phenomenon in order<br />
to underst<strong>and</strong> it fully. This is a hermeneutic process used by Davidson<br />
(1988) <strong>and</strong> described by Wilber in his AQUAL or all-quadrant thinking as<br />
“the eye of the spirit” (Wilber, 1997). Through this process, the multiple<br />
perspectives are synthesized through the lens of the observer; meaning is<br />
cocreated between the observer <strong>and</strong> multiple sources of knowledge, <strong>and</strong><br />
wisdom replaces knowledge development.<br />
<strong>Nursing</strong> practice will incorporate complexity thinking in the development<br />
of practice models <strong>and</strong> through the use of technologies for practice.<br />
The complexity of the health care environment is at a critical point, exhibiting<br />
the characteristics of a system in chaos that is at or approaching a bifurcation<br />
point. At this choice point, nursing, the profession that holds the energy of<br />
love, relationship, <strong>and</strong> compassion, may present a path in which both caring,<br />
technology, <strong>and</strong> the realities of economics may by synthesized in harmony<br />
(Ray, 1994). This can be combined with attention to a high-touch/high-tech<br />
world of practice for nursing. <strong>For</strong> example, new technology at the bedside<br />
may provide a holistic narrative of what is most important to the person,<br />
including his/her preferred name, interests, culture, family, community, <strong>and</strong><br />
what is meaningful. At the same bedside, there will be the integrated patient<br />
record, incorporating relevant <strong>and</strong> current data, <strong>and</strong> technology to enable<br />
the ability to access information <strong>and</strong> knowledge for providing safe, effective<br />
care. This attention to caring may be a stimulus for the higher order of caring<br />
in nurses (Clark, 2003).<br />
The American Nurses Credentialing Center requires hospitals aspiring<br />
to or achieving Magnet status to have a professional practice model that<br />
reflects nursing theory. In this way, the practice environment is creating<br />
an alignment of nursing knowledge for practice. <strong>Nursing</strong> theories in the<br />
unitary–transformation paradigm reflect complexity thinking, <strong>and</strong> there is<br />
accelerated movement of these theories into the practice environment. <strong>For</strong><br />
example, Watson’s Caritas Consortium is a group of health care organizations<br />
that are advancing caring-based practice models that reflect the tenets of
1: Philosophical <strong>and</strong> Theoretical Perspectives 17<br />
complexity, such as interconnectedness, creative emergence, <strong>and</strong> dynamism.<br />
Nurses in practice will be generating <strong>and</strong> testing the concepts within chaos<br />
<strong>and</strong> complexity thinking (Haigh, 2002).<br />
Finally, nursing education will incorporate complexity science in its<br />
approaches to teaching <strong>and</strong> learning. The Carnegie Foundation report on<br />
the nursing education (Benner, Sutphen, Leonard, & Day, 2010) includes<br />
commentary on the chaotic, dysfunctional U.S. health care system <strong>and</strong><br />
how nursing students must learn to function within it. The study found<br />
that nurses are undereducated for practicing in this chaotic health care<br />
system. <strong>For</strong> this reason, nursing educators will be challenged to prepare<br />
students for practice in complex environments. This will require ab<strong>and</strong>oning<br />
a focus on delivering content <strong>and</strong> instead teaching students how to<br />
access <strong>and</strong> use knowledge in the context of dynamic patient care situations<br />
within complex systems. <strong>Nursing</strong> students need practice in clinical<br />
reasoning <strong>and</strong> clinical imagination, thinking through what can happen<br />
as changes occur in patient care situations, <strong>and</strong> creatively responding to<br />
these situations. In addition, nurse educators need to attend to the formation<br />
of the student as person. This formation requires the development of<br />
personhood <strong>and</strong> may involve the use of reflective <strong>and</strong> spiritual practices<br />
<strong>and</strong> aesthetic engagement. Such practices will exp<strong>and</strong> awareness in order<br />
to better apprehend patterns of the whole <strong>and</strong> to live a compassionate<br />
practice. Benner et al. (2010) describe the importance of teaching ethical<br />
comportment, day-to-day living, <strong>and</strong> the essential values of nursing<br />
in practice. The necessary content <strong>and</strong> practice competencies must be<br />
embedded in patient narratives or stories. In this way, the nursing content<br />
currently taught is viewed within the context for promoting the health,<br />
healing, <strong>and</strong> quality of life for the person, family, <strong>and</strong> the community. The<br />
complexity of the nursing situation can be revealed through the story’s<br />
details, <strong>and</strong> knowledge related to nursing science as well as pathophysiology<br />
<strong>and</strong> disease management can be integrated <strong>and</strong> explored within it.<br />
Students need to learn complexity thinking <strong>and</strong> how to underst<strong>and</strong> <strong>and</strong><br />
negotiate the complex environments in which they work. Skills for pattern<br />
seeing, systems thinking, <strong>and</strong> facilitating patient transitions will be essential<br />
for the future. Students will learn through simulations that can embed<br />
complexity within a safe environment. In a health care environment characterized<br />
by interrelationships <strong>and</strong> diversity, learning needs to occur with<br />
other professional students <strong>and</strong> with diverse communities.<br />
<strong>Complexity</strong> thinking is penetrating the consciousness of many disciplines,<br />
including nursing. Martha Rogers described in 1970 a unitary worldview<br />
consistent with complexity theory, making nursing the pioneer in<br />
advancing these ideas. Other nursing theorists have followed, exp<strong>and</strong>ing<br />
complexity thinking in nursing. The concepts within the science of complexity<br />
will shape the future of nursing inquiry, practice, <strong>and</strong> education.
18 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
References<br />
Ackoff, R. (1981). Creating the corporate future: Plan or be planned for. New York:<br />
Wiley.<br />
Allen, P. (2001). What is complexity science? Knowledge of the limits to knowledge.<br />
Emergence, 3(1), 24–42.<br />
Barrett, E. A. M. (1986). The principle of helicy: The relationship of human field<br />
motion <strong>and</strong> power. In V. M. Malinski (Ed.), Explorations on Martha Rogers’ science<br />
of unitary human beings (pp. 173–188). Norwalk, CT: Appleton-Century-Crofts.<br />
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical<br />
transformation. New York: Jossey-Bass.<br />
Bohm, D. (1980). Wholeness <strong>and</strong> the implicate order. London: Routledge.<br />
Briggs, J., & Peat, F. D. (1989). Turbulent mirror: An illustrated guide to chaos theory<br />
<strong>and</strong> the science of wholeness. New York: Harper & Row.<br />
Capra, F. (1982). The turning point: <strong>Science</strong>, society & <strong>and</strong> the rising culture. New York:<br />
Simon & Schuster.<br />
Chaffee, M. W., & McNeill, M. M. (2007). A model of nursing as complex adaptive<br />
system. <strong>Nursing</strong> Outlook, 55, 232–241.<br />
Clark, C. (2003). The transpersonal caring moment: Evolution of higher ordered<br />
beings. International Journal of <strong>Human</strong> <strong>Caring</strong>, 7(3), 30–39.<br />
Cooksley, R. W. (2001). What is complexity science? A contextually grounded tapestry<br />
of systemic dynamism, paradigm diversity, theoretical eclecticism, <strong>and</strong> organizational<br />
learning. Emergence, 3(1), 77–103.<br />
Coppa, D. F. (1993). Chaos theory suggests a new paradigm for nursing science.<br />
Journal of Advanced <strong>Nursing</strong>, 18(6), 985–991.<br />
Davidson, A. W. (1988). Choice patterns: A theory of human-environment relationship.<br />
Unpublished doctoral dissertation, University of Colorado, Boulder, Colorado.<br />
Davidson, A. W., & Ray, M. A. (1991). Studying the human-environment phenomenon<br />
using the science of complexity. Advances in <strong>Nursing</strong> <strong>Science</strong>, 14(2), 73–87.<br />
Davidson, A. W., Teicher, M., & Bar-Yam, Y. (1997). The role of environmental<br />
complexity in the well-being of the elderly. <strong>Complexity</strong> <strong>and</strong> Chaos in <strong>Nursing</strong>, 3,<br />
5–12.<br />
Dent, E. B. (2000). <strong>Complexity</strong> science: A worldview shift. Emergence, 11(4), 5–19.<br />
Fawcett, J. (2000). Analysis <strong>and</strong> evaluation of contemporary nursing knowledge:<br />
<strong>Nursing</strong> models <strong>and</strong> theories. Philadelphia: F. A. Davis.<br />
Ferguson, M. (1980). The aquarian conspiracy: Personal <strong>and</strong> social transformation in<br />
the1980s. Los Angeles: J. P. Tarchers.<br />
Gleick, J. (1987). Chaos: Making a new science. New York: Viking.<br />
Haigh, C. (2002). Using chaos theory: Implications for nursing. Journal of Advanced<br />
<strong>Nursing</strong>, 37(5), 462–468.<br />
Harman, W. (1998). Global mind change: the promise of the last years of the twentieth<br />
century. Indianapolis, IN: Knowledge Systems.<br />
Horgan, J. (1995). From complexity to perplexity. Scientific American, 5, 104–109.<br />
Koithan, M. (2006). Models for the study of whole systems. Integrative Cancer Therapies,<br />
5(4), 293–307.<br />
Lewin, R. (1992). <strong>Complexity</strong>: Life at the edge of chaos. New York: Macmillan.<br />
Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: <strong>Nursing</strong> in the age of complexity.<br />
Bordentown, NJ: Plexus Press.
1: Philosophical <strong>and</strong> Theoretical Perspectives 19<br />
Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image,<br />
22(4), 256–262.<br />
Newman, M. (1986). Health as exp<strong>and</strong>ing consciousness. St. Louis, MO: Mosby.<br />
Newman, M. (1994). Health as exp<strong>and</strong>ing consciousness. St. Louis, MO: Mosby.<br />
Newman, M. (2008). Transforming presence: The difference nursing makes. Philadelphia:<br />
F. A. Davis.<br />
Newman, M. A., Sime, M., & Corcoran-Perry, S. (1991). The focus of the discipline of<br />
nursing. Advances in <strong>Nursing</strong> <strong>Science</strong>, 14(1), 1–6.<br />
Newman, M. A., Smith, M. C., Dexheimer-Pharris, M., & Jones, D. (2008). The<br />
focus of the discipline of nursing revisited. Advances in <strong>Nursing</strong> <strong>Science</strong>, 31(1),<br />
E16–E27.<br />
Parse, R. R. (1981). Man-living-health: A theory of nursing. New York: Wiley.<br />
Parse, R. R. (1998). The human becoming school of thought. Philadelphia, Thous<strong>and</strong><br />
Oaks, CA: Sage.<br />
Parse, R. R., Coyne, A. B., & Smith, M. J. (1987). <strong>Nursing</strong> science: Paradigms, theories<br />
<strong>and</strong> critiques. Philadelphia: W. B. Saunders.<br />
Phelan, S. E. (2001). What is complexity science? Emergence, 3(1), 120–136.<br />
Prigogine, E., & Stengers, I. (1984). Order out of chaos: Man’s new dialogue with nature.<br />
Toronto, ON: Bantam Books.<br />
Ray, M. (1994). Complex caring dynamics: A unifying model of nursing inquiry.<br />
Theoretic <strong>and</strong> Applied Chaos in <strong>Nursing</strong>, 1(1), 23–32.<br />
Ray, M. (1998). <strong>Complexity</strong> <strong>and</strong> nursing science. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 11(3),<br />
91–93.<br />
Reed, P. (1991). Toward a nursing theory of self-transcendence: Deductive reformulation<br />
using developmental theories. Advances in <strong>Nursing</strong> <strong>Science</strong>, 13(4), 64–77.<br />
Resnicow, K., & Page, S. E. (2008). Embracing chaos <strong>and</strong> complexity: A quantum<br />
change for public health. American Journal of Public Health, 98(8), 1382–1389.<br />
Richardson, K. A., & Cilliers, P. (2001) What is complexity science? A view from different<br />
directions. Emergence, 3(1), 5–23.<br />
Richardson, K. A., Cilliers, P., & Lissack, M. (2000). <strong>Complexity</strong> science: A grey science<br />
for the stuff in between. Proceedings of the first International Conference on Systems<br />
Thinking in Management. Geelong, Australia, 532–537.<br />
Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia:<br />
F. A. Davis.<br />
Rogers, M. E. (1990). <strong>Nursing</strong>: <strong>Science</strong> of unitary, irreducible human beings: Update<br />
1990. In E. A. M. Barrett (Ed.), Visions of Rogers’ <strong>Science</strong>-based <strong>Nursing</strong> (pp. 5–11).<br />
New York: National League for <strong>Nursing</strong> Press.<br />
Rogers, M. E. (1994). The science of unitary human beings: Current perspectives.<br />
<strong>Nursing</strong> <strong>Science</strong> Quarterly, 7(1), 33–35.<br />
Roy, C. (2008). The Roy Adaptation Model (3rd ed.). Upper Saddle River, NJ: Prentice<br />
Hall Health.<br />
Roy, C., & Jones, D. (Eds.). (2007). <strong>Nursing</strong> knowledge development <strong>and</strong> clinical practice.<br />
New York: Springer.<br />
Roy, C. & Zhan, L. (2010). Sister Callista Roy’s adaptation model. In M. Parker & M. Smith<br />
(Eds.), <strong>Nursing</strong> theories & nursing practice (3rd ed., pp. 167–181). Philadelphia:<br />
F. A. Davis Company.<br />
Schwartz, P., & Ogilvy, J. A. (1979). The emergent paradigm: Changing patterns of<br />
thought <strong>and</strong> belief. Menlo Park, CA: SRI International.
20 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
Smith, M. C. (1994). Arriving at a philosophy of nursing. In J. F. Kikuchi & H. Simmons<br />
(Eds.), Developing a philosophy of nursing (pp. 43–60). Thous<strong>and</strong> Oaks, CA: Sage.<br />
Stacey, R., Griffen, D., & Shaw, P. (2000). <strong>Complexity</strong> <strong>and</strong> management. London <strong>and</strong><br />
New York: Routledge.<br />
Turkel, M. C., & Ray, M. A. (2000). Relational complexity: A theory of the nursepatient<br />
relationship within an economic context. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 13(4),<br />
307–313.<br />
Turkel, M. C., & Ray, M. A. (2001). Relational complexity: From grounded theory to<br />
instrument development <strong>and</strong> theoretical testing. <strong>Nursing</strong> <strong>Science</strong> Quarterly, 14(4),<br />
281–287.<br />
Vicenzi, A. (1994). Chaos theory <strong>and</strong> some nursing considerations. <strong>Nursing</strong> <strong>Science</strong><br />
Quarterly, 7(1), 36–42.<br />
Wilber, K. (1997). The eye of the spirit. New York: R<strong>and</strong>om House.<br />
Wilber, K. (1998). The marriage of sense <strong>and</strong> soul: Integrating science <strong>and</strong> religion.<br />
New York: R<strong>and</strong>om House.<br />
Young, A. (1976). The reflexive universe: Evolution of consciousness. San Francisco:<br />
Robert Briggs.
21<br />
Response to Chapter 1<br />
Reflective Questions<br />
Joyce Perkins<br />
1. What is the relationship between theory <strong>and</strong> practice (clinical,<br />
administrative or educational) highlighted in this chapter?<br />
The most important relationship between theory <strong>and</strong> practice highlighted<br />
in this chapter is that found in the unitary-transformative or<br />
simultaneity paradigm as described in the nursing literature. This world<br />
view notes the human-environment as a unitary whole. As such, the<br />
theory is the practice, <strong>and</strong> may be said to happen or unfold via the<br />
direct perception of the nurse. As nurses, theory is the cognitive or<br />
conceptual framework that maps the terrain of our work <strong>and</strong> world.<br />
Practice is the lived experience of a certain perspective or theoretical<br />
world view embodied within the nurse. Theory is our way of organizing<br />
<strong>and</strong> bringing clarity to the process of living life <strong>and</strong> working with<br />
our patients. Practice is the direct experience of what works or does<br />
not work in the “field” of patient care. This constant interplay or daily<br />
feedback exp<strong>and</strong>s the awareness of the nurse exponentially, exp<strong>and</strong>ing<br />
consciousness with the emergence of new insights in a consistent, even<br />
rhythmic way, in relation to the intensity of the situations presented.<br />
Nurses enter into relationship with patients in times of crisis or “bifurcation<br />
points”. They are poised to help initiate shifts in the lives of persons<br />
who enter into a caring relationship with them.<br />
In this chapter, Smith explicates the complexity of this relationship<br />
between nurse, patient, <strong>and</strong> environment. She traces the origins of what<br />
is fast becoming the “map” of choice across multiple venues including<br />
clinical practice, administration, <strong>and</strong> educational institutions.<br />
In clinical practice, an example of this model of nursing care is<br />
displayed by nurses on a depression, mood disorder, in-patient hospital<br />
unit in a large tertiary care hospital in the Midwest. These nurses practice<br />
what is referred to as “relationship centered care” (Suchman, 2006)<br />
by putting the patient’s needs first. They also practice what is called<br />
“unitary-caring science” in nursing. Unitary caring science is described<br />
as a melding of Roger’s <strong>Science</strong> of Unitary <strong>Human</strong> Beings <strong>and</strong> Watson’s<br />
Transpersonal <strong>Caring</strong> Theory. They go about their work with patients<br />
modeling the complexity descriptions noted by Butcher (2002) as:<br />
1) cultivating creativity, 2) using butterfly power, 3) flowing with turbulence,
22 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
4) exploring integrality, 5) seeing the beauty <strong>and</strong> art of nursing,<br />
7) living in pan dimensionality, <strong>and</strong> 8) participating with the whole.<br />
Each of these themes describes a quality specific to complexity science<br />
but also to unitary caring science.<br />
In administrative relationships, a complexity model of operating may<br />
be seen in the literature <strong>and</strong> in the style of management that encourages<br />
a non-hierarchal approach to problem solving <strong>and</strong> transformational<br />
leadership. Margaret Wheatley (2001) has been the spokes person for<br />
this creative venue that brings all participants to the table, giving voice<br />
to potential <strong>and</strong> emergent possibilities for resolving complex problems.<br />
Knowing the difference between simple, complicated <strong>and</strong> complex problems<br />
(Zimmerman, 1999) allows nurses the opportunity to choose the<br />
most efficient avenue for resolution, choosing to focus their efforts in<br />
paradigm I, II, or III as articulated by Newman et al. (1991).<br />
In education, teaching complexity principles to student nurses brings<br />
light bulb moments in the class room as they grasp the implications of<br />
functioning with these essential guidelines alongside them. <strong>Complexity</strong><br />
principles are “essential” in that all of nature follows the process mapped<br />
by complexity science. It inherently makes sense, <strong>and</strong> at the same time<br />
lends a refreshing <strong>and</strong> inspiring vision that uplifts the spirit. In this chapter<br />
Smith has managed to take an often overwhelmingly complex subject<br />
<strong>and</strong> revealed the path by giving us navigational tools to help make sense<br />
of our world <strong>and</strong> our individual roles in the global scheme of things.<br />
From the microscopic to the macroscopic or cosmic environment, from<br />
the quantum wave/particle to the path of stars <strong>and</strong> planets, all may be<br />
better understood as fractal elements of the universal design of our cosmos.<br />
The term “fractal” refers to the shapes <strong>and</strong> patterns found in nature<br />
that are iterative or repeat at all levels of design or dimension, each<br />
embedded within the one before. Information is shared, distributed in<br />
this way via a non local process as stated in complexity theory.<br />
Nurses are constantly placed in situations that facilitate an accelerated<br />
learning curve as they walk 24/7 alongside their patients. As they<br />
choose to step into caring relationships with each other <strong>and</strong> with their<br />
patients, our world becomes a better place <strong>and</strong> we all become healthier<br />
people. In complexity science, nurses now have a map which affirms<br />
our historical nursing theories, yet also inspires a new <strong>and</strong> dynamic<br />
approach. As each nurse individually grasps the concepts <strong>and</strong> makes<br />
them his/her own, a new life <strong>and</strong> energy is brought to the fore. In<br />
complexity science, we have the patterns <strong>and</strong> dynamics that express<br />
how one can both express individually yet be globally connected <strong>and</strong><br />
conscious in a deeply caring <strong>and</strong> inspired way.
1: Philosophical <strong>and</strong> Theoretical Perspectives 23<br />
2. How does a nurse or a physician or health care administrator learn<br />
about complexity science/s <strong>and</strong> caring through the presentation of<br />
ideas or research?<br />
People exp<strong>and</strong> their horizons of meaning by being in dialogue with one<br />
another. Truly listening or hearing what each other is saying is imperative.<br />
By learning something of the various cultural perspectives we<br />
enrich the dialogue <strong>and</strong> ourselves by being able to envision new possibilities<br />
or other ways of knowing <strong>and</strong> doing. The natural world demonstrates<br />
the unfolding of complexity principles, so paying attention<br />
<strong>and</strong> having the intention to learn is particularly helpful. There are many<br />
short videos available on line now to assist one in grasping graphically<br />
or visually principles that may be difficult if just the verbal description<br />
is offered. We are becoming a multi sensory population <strong>and</strong> there are<br />
tools that can be shared to open up these doorways for exploration.<br />
Indigenous people who think in images instead of words are showing<br />
us the way in many respects. Learning to pay attention to intuition,<br />
“feeling” dynamics, <strong>and</strong> subtle impressions brings the world to life in a<br />
way that objective rational thinking has left void.<br />
3. What meanings are illuminated in this chapter for nursing or other<br />
health care professions? Direct your answer to education, administration,<br />
research or practice based upon the focus of the chapter.<br />
The meanings illuminated in this chapter for nursing <strong>and</strong> other health<br />
care professionals are as follows:<br />
a. Nurse educators must now teach about the world <strong>and</strong> nature as<br />
it really is, not as isolated phenomena but in context with many<br />
influences <strong>and</strong> dimensions to consider. We are to enjoy the process.<br />
In other words, we are to come from a place of love in the heart<br />
instead of fear. Surprising <strong>and</strong> amazing happenings unfold as we<br />
work in harmony <strong>and</strong> synchronicity with all that is. A resonance<br />
pervades that unifies our efforts in mighty ways. Native peoples<br />
would say that we follow the “beauty way.”<br />
b. Nurse administrators need to avoid “top down” hierarchical models.<br />
They need to obtain input from the “bottom-up,” bringing all players<br />
to the table to make decisions, especially those who will be<br />
doing the work. More insight into problem situations comes into<br />
play when one includes outliers with unique perspectives. Outliers<br />
are seen as valuable players rather than irritations to be ignored<br />
as in the traditional paradigm of medical science or paradigm I in<br />
nursing. In <strong>Complexity</strong> dynamics we have a “both/<strong>and</strong>” philosophy<br />
in which each perspective plays its part. In all, workers take more<br />
responsibility for decisions that they have helped to create.
24 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
c. Nurse researchers must now resolve the paradox of duality perspectives<br />
with an exp<strong>and</strong>ed vision. Quantitative <strong>and</strong> Qualitative,<br />
reductionist <strong>and</strong> pluralistic measures, <strong>and</strong> many other qualities<br />
listed in this chapter co-exist each with their purpose, but we are<br />
rising to a new level of operating within ourselves. As consciousness<br />
exp<strong>and</strong>s individually, the collective consciousness also takes a<br />
leap. New research methods must be devised that actually speak to<br />
this new reality. We live in a quantum world that “leaps” to surprising<br />
solutions, no longer just using rational linear logic to explore<br />
our world.<br />
d. Practicing nurses are embedded in the mix of patient dilemmas.<br />
Solutions emerge from constant feedback as new information is<br />
digested <strong>and</strong> recycled through creative applications to problematic<br />
areas. Nurses need to get used to change, be flexible, <strong>and</strong> become<br />
comfortable with uncertainty, learning to tap into “group mind”<br />
where solutions lay waiting for one who asks. Life takes on a vitality<br />
that can only come from needing to stay awake <strong>and</strong> on ones<br />
toes. Not at all the boring <strong>and</strong> tedious actions called forth under a<br />
predictable conceptual model of the universe. All becomes important<br />
<strong>and</strong> each is needed to do his/her part for the whole to radiate<br />
a mature persona of love <strong>and</strong> kindness.<br />
4. What is the relevance of this work to the future of the discipline <strong>and</strong><br />
profession of nursing, health care professions <strong>and</strong> health care in<br />
general?<br />
<strong>Nursing</strong>, at its best, has always worked with the idea of compassion,<br />
which means to join with passion or enthusiasm into the endeavor at<br />
h<strong>and</strong>. Nurses facilitate well being or the healing process for <strong>and</strong> with<br />
others. Nurses have always been in full participation in that they walk<br />
along side their patients rather than act as hierarchical dictators of<br />
orders. Nurses are thus, ready to move forward with complexity thinking.<br />
As a group, nurses do not have energy invested in hierarchical<br />
power structures. <strong>Complexity</strong> <strong>Science</strong> coupled with caring dynamics<br />
seems to be our true language, our way of being in the world. We have<br />
always considered multiple options <strong>and</strong> avenues for exploration to help<br />
take us toward the focus of our attention <strong>and</strong> intention. That focus is to<br />
care for our patients, ourselves, <strong>and</strong> experience a harmony of wholeness<br />
<strong>and</strong> health of body, mind <strong>and</strong> spirit.<br />
<strong>Complexity</strong> thinking is the venue that will allow us the quantum<br />
leap forward in our ability to solve previously inexplicable problems.<br />
Other health professions as they come to underst<strong>and</strong> the dynamics of a<br />
complexity model will be more willing to engage with one another for
1: Philosophical <strong>and</strong> Theoretical Perspectives 25<br />
mutual benefit, each bringing the wisdom of their way of doing things.<br />
We will learn to work together <strong>and</strong> share the responsibility for our own<br />
health <strong>and</strong> healing along with that of our earth.<br />
References<br />
Butcher, H. (2002). Living in the heart of helicy: An inquiry into the meaning of compassion<br />
<strong>and</strong> unpredictability in rogers’ nursing science. Visions, 10(1) 6–22.<br />
Newman, M., Sime, A., Corcoran-Perry, S. (1991). The focus of the discipline of nursing.<br />
Advances in <strong>Nursing</strong> <strong>Science</strong>, 14(1), 1–6.<br />
Suchman, A. L. (2006). A new theoretical foundation for relationship-centered<br />
care: Complex responsive processes of relating. Journal of General Internal<br />
Medicine, 21, S40.<br />
Wheatley, M. J. (2001). Restoring hope to the future through critical education of<br />
leaders. The Journal for Quality <strong>and</strong> Participation, 24(3), 46.<br />
Zimmerman, B. (1999). <strong>Complexity</strong> science: A route through hard times <strong>and</strong> uncertainty.<br />
Health <strong>For</strong>um Journal, 42(2), 42.
26<br />
Response to Chapter 1<br />
reflections from a rogerian science perspective<br />
Francelyn M. Reeder<br />
Thoughts on the <strong>Science</strong> of Unitary <strong>Human</strong> Beings<br />
The <strong>Science</strong> of Unitary <strong>Human</strong> Beings (SUHB) (Rogers, 1970), the conceptual<br />
system of the nursing theorist Martha Rogers, is its own unique science with<br />
its origin in the unitary nature of the human–environment mutual process.<br />
<strong>Nursing</strong> is a science <strong>and</strong> an art. “A science is an organized abstract system.<br />
It is a synthesis of facts <strong>and</strong> ideas, a new product” (Rogers, 1990, p. 6).<br />
A science has many theories. The mutual human–environment process is the<br />
focus of nursing; it is complex <strong>and</strong> often difficult to study. The abstract system<br />
of the SUHB exists as an irreducible whole. Definitions, principles, <strong>and</strong><br />
theories derive from this irreducible whole. “The evolution of unitary human<br />
beings is a dynamic, irreducible, nonlinear process characterized by increasing<br />
diversity of energy field patterning” (Rogers 1990, p. 9). Thus, developing<br />
nursing’s abstract system dem<strong>and</strong>s a new worldview, a language that has<br />
specificity, clarity, precision, <strong>and</strong> communication (Rogers, 1990). Although the<br />
<strong>Science</strong> of Unitary <strong>Human</strong> Beings is often directly compared with complexity<br />
sciences, I believe that the SUHB can be classified as different because<br />
of the unique principles that are espoused <strong>and</strong> the wholeness expressed in<br />
the life process as reflected in pattern manifestation <strong>and</strong> organization in the<br />
energy fields of humans <strong>and</strong> environment. Rogers did not use the language<br />
of complexity, such as chaos theory, complex adaptive systems, or from a<br />
physiological view, normal variability, or from a methods perspective, fractal<br />
analysis to identify or analyze fractal patterns <strong>and</strong> the interactive process that<br />
creates them. Rogers, on the other h<strong>and</strong>, advocated multiple naturalistic field<br />
methods or forms of inquiry to study phenomena within context, recognizing<br />
the unitary nature between the observer <strong>and</strong> the observed or that the knower<br />
<strong>and</strong> the known are one (Reeder, 1984). Rogers (1990) used the revised homeodynamic<br />
principles of resonancy, helicy, <strong>and</strong> integrality to underst<strong>and</strong> <strong>and</strong><br />
study the continuous human <strong>and</strong> environmental process (p. 97). “Resonancy<br />
refers to continuous change from lower to higher frequency wave patterns in<br />
human <strong>and</strong> environmental fields. Helicy refers to the continuous innovative,<br />
unpredictable, increasing diversity of human <strong>and</strong> environmental field patterns.<br />
Integrality refers to continuous mutual human field <strong>and</strong> environmental field<br />
process” (Rogers, 1990, p. 8). These principles provide a fundamental guide to<br />
the study <strong>and</strong> practice of nursing. The SUHB begins with the unitary nature<br />
of humans in the environment, which is in mutual process <strong>and</strong> continuously
1: Philosophical <strong>and</strong> Theoretical Perspectives 27<br />
moving forward. The increasing complexification of energy field patterning<br />
shows that there is no generalization from parts to whole (Rogers, 1990).<br />
Outcome subsequently is not the origin, nor is the science a stimulus–<br />
response system, nor is it divisible into parts. Consequences or conclusions<br />
although may be captured as pattern outcomes in research, however, are not<br />
applicable in the strict sense of the words. Thus complexity science, although<br />
illuminating the relationship networks or the tenet of interconnectedness, is<br />
different from Rogerian science.<br />
Philosophically, Rogers’ SUHB is essentially unitary. Its essence of meaning<br />
always begins with the unitary nature of the human <strong>and</strong> environment in<br />
mutual process, which is continually open to pattern change. As a unitary<br />
mutual human–environment process, complex patterns become manifest as<br />
humans <strong>and</strong> their environment dynamically evolve; they are unpredictable<br />
<strong>and</strong> increasingly diverse.<br />
From an inquiry perspective, complex ways of knowing are manifest<br />
<strong>and</strong> unfold in the real world. The SUHB always encompasses the everchanging<br />
human–environment integrality, including the environment, for<br />
example, of space. Rogers reinforced the phrase advanced by Robinson<br />
<strong>and</strong> White (1986), home spatialis, to illuminate the ever-changing human–<br />
environment field patterning. <strong>Complexity</strong>, thus, is interpreted through<br />
a lens—a telescope to look at humans in a real-world mutual process.<br />
These manifestations are experienced in practice, studied in research, <strong>and</strong><br />
communicated in education.<br />
Application of the SUHB in <strong>Nursing</strong> Research,<br />
Education, <strong>and</strong> Practice<br />
Unitary field pattern methods or the study of pattern manifestations have<br />
been advanced by Rogerian scholars, such as Rawnsley, Butcher, <strong>and</strong> Cowling<br />
(Madrid & Barrett, 1994; Locsin & Purnell, 2009). Complex field patterning<br />
manifestations of the human–environment mutual process in practice can<br />
be interpreted by nurses through education, research, <strong>and</strong> practice. Nurses<br />
are not separate from patients; they are in an integral relationship manifest<br />
as integral evidence. Persons intended are ever changing, never static,<br />
transcendent as well as immanent, <strong>and</strong> potential as well as actual; as such,<br />
preference is given to wave-seeing (whole) rather than particle-seeing (parts)<br />
consideration or judgment in the world. The benefit of underst<strong>and</strong>ing integral<br />
evidence “. . . holds promise for the development of pattern seeing of<br />
wave phenomena” (Reeder, 1984, p. 21) in Rogers’ <strong>Science</strong> of Unitary <strong>Human</strong><br />
Beings. The integral evidence, observational statements or communicative<br />
phenomena of “consciousing the world” or manifesting intentional consciousness,<br />
can be, for example, energy as felt, healing as imagined, health<br />
as remembered or health as desired, pain as avoided, <strong>and</strong> action as judged.
28 NURSING, CARING, AND COMPLEXITY SCIENCE<br />
The integral evidence includes not only five sense perceptible things but also<br />
phenomena such as willing, loving, judging, imagining, remembering, intuiting,<br />
feeling, <strong>and</strong> anticipating (Reeder, 1984). Learned pattern seeing in nursing<br />
adopting the SUHB for research, education, <strong>and</strong> practice must come from<br />
a centered perspective of knowledgeable compassion. “art, wisdom <strong>and</strong> compassion,<br />
underwritten by transcendent imaginative conceptual skill index the<br />
ways of knowing that are integral to this unique science of nursing” (Reeder,<br />
1984, p. 23). Knowledge <strong>and</strong> wisdom thus are lived uniquely by the knower<br />
<strong>and</strong> the known (Mitchell, 2009). Rogers taught us to appreciate that “as individuals<br />
attune to a unity consciousness [the unity of the knower <strong>and</strong> the<br />
known], infinite possibilities are born, <strong>and</strong> the status of finite consciousness<br />
disappears in the beauty <strong>and</strong> flow, revealing a kaleidoscope of patterns that<br />
are ever-changing” (Cowling & Repede, 2009, p. 78). As Einstein revealed,<br />
the most beautiful thing that we can experience is the mysterious; the source<br />
of all true art <strong>and</strong> science is the mysterious (Madrid & Barrett, 1994, xix).<br />
In nursing, we hold this beauty <strong>and</strong> mystery in our h<strong>and</strong>s, hearts, <strong>and</strong> minds<br />
through knowledge <strong>and</strong> the wisdom of Rogers’ incomparable <strong>Science</strong> of<br />
Unitary <strong>Human</strong> Beings.<br />
References<br />
Cowling, R., & Repede, E. (2009). Consciousness <strong>and</strong> knowing: The patterning of the<br />
whole. In R. Locsin & M. Purnell (Eds.), A contemporary nursing process: The (un)<br />
bearable weight of knowing in nursing (pp. 73–121). New York: Springer.<br />
Madrid, M., & Barrett, E. (Eds.). (1994). Rogers’ scientific art of nursing practice.<br />
New York: National League for <strong>Nursing</strong> Press.<br />
Mitchell, G. (2009). Evidence, knowledge, <strong>and</strong> wisdom: <strong>Nursing</strong> practice in a universe of<br />
complexity <strong>and</strong> mystery. In R. Locsin & M. Purnell (Eds.), A contemporary nursing process:<br />
The (un)bearable weight of knowing in nursing (pp. 99–121). New York: Springer.<br />
Reeder, F. (1984). Philosophical issues in the Rogerian science of unitary human<br />
beings. Advances in <strong>Nursing</strong> <strong>Science</strong>, 8(1), 14–23.<br />
Robinson, G., & White, H. (1986). Envoys of mankind. Washington, DC: Smithsonian<br />
Institute Press.<br />
Rogers, M. (1970). An introduction to the theoretical basis of nursing. Philadelphia:<br />
F. A. Davis.<br />
Rogers, M. (1990). <strong>Nursing</strong>: <strong>Science</strong> of unitary, irreducible, human beings: Update 1990.<br />
In E. Barrett (Ed.), Visions of Rogers’ science-based nursing (pp. 5–11). New York:<br />
National League for <strong>Nursing</strong>.
1: Philosophical <strong>and</strong> Theoretical Perspectives 29<br />
Chapter 1<br />
Philosophical <strong>and</strong> Theoretical Perspectives Related<br />
to <strong>Complexity</strong> <strong>Science</strong> in <strong>Nursing</strong><br />
n<br />
n<br />
n<br />
n<br />
n<br />
n<br />
How do you see the work of Martha Rogers’ science (the <strong>Science</strong><br />
of Unitary <strong>Human</strong> Beings) influencing contemporary health<br />
care practices?<br />
Do you see Martha Rogers’ work more congruent with caring<br />
science or complexity science?<br />
How do you see caring science <strong>and</strong> complexity sciences guiding<br />
your professional practice? Discuss some concepts from Watson’s<br />
“Caritas” theory <strong>and</strong> the <strong>Science</strong> of Unitary <strong>Human</strong> Beings. Are<br />
they comparable?<br />
In the response, Dr. Perkins defines “fractal”; what shape or<br />
pattern found in nature best describes your professional work<br />
environment?<br />
In the response, Dr. Perkins talks about the importance of integrating<br />
concepts from complexity into education. What education<br />
would your peers need to make the connection between the<br />
theory of complexity sciences <strong>and</strong> professional practice?<br />
In the response, Dr. Reeder speaks of Rogers’ <strong>Science</strong> of<br />
Unitary <strong>Human</strong> Beings. What does unitary mean to you both<br />
from a Rogerian point of view <strong>and</strong> how you have developed the<br />
idea?